
Class _3_X-4L-U-k_ 

Book ,r"5^> 

Copyright^ 



COPYRIGHT DEPOSrr. 



INFANT-FEEDING 

IN ITS RELATION TO 

HEALTH AND DISEASE 
FISCHER 



INFANT-FEEDING 



IN ITS RELATION TO 



Health and Disease 



BY 

LOUIS FISCHER, M.D. 

Visiting Physician to the Willard Parker and Riverside Hospitals of New York City; Attending 

Physician to the Children's Service of the New York German Polikliuik ; Former 

Instructor in Diseases of Children at the New York Post-graduate 

Medical School and Hospital, etc., etc. ; Fellow of the 

New York Academy of Medicine. 



Containing 54 Illustrations, with 24 Charts and 
Tables, Mostly Original 



TJilSD BDITIOfl 




Philadelphia 

F. A. DAVIS COMPANY, PUBLISHERS 

19U3 



THE 

Copiei R»- 

OCT 23 < 

Cop> righl cnl>) 
CLASS CL *> 

c ■ : 






COPYRIGHT, 1903, 

BY 

F. A. DAVIS COMPANY. 



[Registered at Stationers' Hall, London, Eng.J 



• . • • 



Philadelphia, Pa., U. S. A. : 

The Medical Bulletin Printing-house, 

1914-16 Cherry Street. 



THIS BOOK 
is 

DEDICATED TO MY FRIEND, 
DR. GEORGE F. SHRADY, 

AS A 

TOKEN OF RESPECT 
FOR HIS STERLING QUALITIES AS A MAN AND 

His Sincerity as a physician. 



PREFACE TO THE TIIIIM) EDITION. 



Tins book has been completely revised; in fact, 
almost entirely rewritten. Many changes were deemed 
necessary to aid the general practitioner in working for- 
mulae required for home-modification of milk. The author 
has omitted the greater part of the former chapter on 
Oaertner mother-milk, inasmuch as the milk is not dis- 
tributed fresh daily, which is so vital. A new chapter, en- 
titled "Milk Idiosyncrasies in Children," showing how chil- 
dren were fed who could not tolerate milk, is added. 

Another new chapter, entitled "Buttermilk Feeding," 
treating of a method of feeding in vogue in foundling 
asylums, has been added, as has also a chapter on "Scurvy." 
The dietary for older children has been enlarged. The 
method of feeding in diphtheria has been rewritten, and 
the method in use at the Willard Parker Hospital is de- 
scribed. A new chapter on "Feeding Children Afflicted 
with Cleft Palate" has been added. 

A great deal of attention has been given to the chapter 
on "Modified Milk from the Walker-Gordon Laboratory." 
Much of what had previously been written on this subject 
has been left out. The author believes that accuracy at 
the laboratory plus clean utensils is of value in many 
cases, and cites a successful modified-milk feeding. 

Some illustrations showing specimens of "Poor breast- 
milk" have been added. In all, this edition may safely be 
trusted to aid those in search of practical points in modern 
methods of breast- and bottle- feeding. 

Louis Fischer. 
August, 1903. 

(ix) 



PREFACE TO THE SECOND EDITION. 



Tins book has undergone a careful revision. A great 
many chapters have been changed; some have been added, 
including a new chapter on "Infant-feeding in Summer 
Complaint/' A new diet for an older child, after weaning 
from the breast or bottle, has also been added. It is also 
a gratification to the author to note the kindly criticisms 
which have appeared in the different medical journals. 
Many of the suggestions which have been offered for im- 
proving the practical value of the book have been carefully 
considered, and numerous additions have been made ac- 
cordingly. 

The utility of this book has been manifested by a call 
for a second edition within six months. 

Louis Fischer. 
September 1, 1901. 



(xi) 



PREFACE TO THE FIRST EDITION. 



Duiuxg ten years' experience in the children's service 
of one of the largest children's clinics in this country the 
author has met with many intricate problems in infant- 
feeding. Besides this, many points were gained, while 
studying abroad, through the wise counsel of Professor 
Adolf Baginsky at the Kaiser and Kaiserin Friedrich Chil- 
dren's Hospital, in Berlin, both in his hospital wards as well 
as in the out-patient department. 

While lecturing on diseases of children at the New 
York Post-graduate School and Hospital, and later while 
instructing at the Xew York School of Clinical Medicine, 
the author has noted the great anxiety with which his 
students, all of whom wpre physicians in active practice, 
requested detailed information regarding the "Modern 
Methods of Infant-feeding." 

The author has therefore felt that if his experience, 
aided by the suggestions of many good text-books, were 
combined to give details pertaining to the feeding of in- 
fants and children requiring breast-feeding or hand-feed- 
ing, — so-called bottle-feeding, — then his work would serve 
as a guide to both the active practitioner and also to the 
beginner in medicine. 

Louis Fischee. 

Go East Ninetieth Street, 
New Yoek City. 



(xiii) 



TABLE OF CONTENTS. 



PART I. 

PAGE 

Chapter I. — Anatomy and Physiology of the Infantile 

Stomach 1 

Chapter II. — Action of Digestive Ferments on Various 

Bacteria 4 

Chapter III. — Stomach-capacity 6 

Chapter IV. — Ferments and Their Actions 11 

Chapter V. — The Intestinal Canal of the Infant 15 

Chapter VI. — Fermentation and Absorption 18 

Chapter VII. — Constituents of Milk 25 

Chapter VIII. — Bacteria of the Intestine 39 

Chapter IX. — Variations of Milk 55 

Chapter X. — Chemical Examination of Breast-milk 60 

Chapter XI. — Breast-feeding and Mixed Feeding 07 

Chapter XII. — Wet-nursing and Weaning 70 

Chapter XIII. — Management of Woman's Nipples 89 

Chapter XIV.— Infant's Weight 92 

Chapter XV.— Raw Cows' Milk 98 

Chapter XVI.— Constituents of Cows' Milk 107 

Chapter XVII. — Buttermilk Feeding 115 

Chapter XVIII. — Detection and Addition of Preservatives to 

Milk 122 

Chapter XIX.— Cream and Modified Milk 134 

Chapter XX. — Water as an Infant's Beverage 142 

Chapter XXI. — Bottle-feeding, or Hand-feeding 144 

Chapter XXII. — Feeding-table and Cream-mixtures 145 

Chapter XXIII. — Home-modification of Milk 148 

Chapter XXIV.— Sterilized Milk 169 

Chapter XXV.— Pasteurized Milk 177 

Chapter XXVI.— Tyndallization 183 

Chapter XXVII.— Nipples and Bottles 185 

Chapter XXVIII.— Dextrinized Gruels 191 

(XV) 



\vi TABLE OF CONTEXTS. 

PART II. 

PAGE 

CHAPTEB XXIX. — Feeding of Infants in Incubators 194 

Chapter XXX.— Aerated and Certified Milk 204 

Chapter XXXI.— Infant-foods 206 

Chapter XXXII.— Milk Substitutes 218 

Chapter XX XIII. — Milk Idiosyncrasies in Children 228 

Chapter XXXIV.— Laboratory Modification of Milk 236 

Chapter XXXV. — Forced Feeding 250 

Chapter XXXVI. — Feeding in Diphtheria-Intubation Cases.. 254 

Chapter XXXVII.— General Rules for Rectal Feeding 258 

Chapter XXXVIII.— Feeding Children Afflicted with Cleft 

Palate 260 

Chapter XXXIX.— Infant-stools 261 

Chapter XL. — Nathan Straus Milk-laboratories and Similar 

Charities 268 

Chapter XLL— Colic 271 

Chapter XLII. — Constipation 275 

Chapter XLIIL— Statistics 286 

Chapter XLIV.— Rachitis 288 

Chapter XLV. — Scurvy 294 

Chapter XLVL— Dentition 299 

Chapter XLVIL — Athrepsia Infantum (Marasmus) 303 

Chapter XLVIII. — Infant-feeding in Summer Complaint .... 317 

Dietary «321 

List of Books Consulted 346 

Index 348 



PART L 



CHAPTER I. 

INTRODUCTION. 

Ix order to understand the difference between the 
various forms of infant-feeding it is necessary to con- 
sider the anatomy and physiology of the very young 
digestive tract. 

The infantile stomach is vertical and cylindrical and 
the fundus but little developed. Thus, whenever there 
is a tendency to vomit, the antiperistaltic motions do 
not press against the fundus, but directly upward. There 
is, therefore, rather an overflow than a vomiting of the 
gastric contents; this takes place so easily that the babies 
are not disturbed by it. 1 

ANATOMY. 

The muscular development is weakest at the fundus. 
According to Fleischmann, the oblique and the longi- 
tudinal fibres described by Henle, which have their origin 
at the pyloric opening, "do not exist in the infant." The 
investigations of Leo and von Puteren show that, in spite 
of this lack of muscular development, the stomach of a 
nursing infant is emptied in one and a half or two hours. 
AVith food that is more difficult to digest, the gastric con- 
tents are propelled more slowly. 

The Mucous Membrane of the Stomach. — The mucous 
glands are far more numerous on the pars pylorica than 
in adults, whereas they are far fewer in number at the 
cardia. 



1 Jacobi, "Therapeutics of Infancy and Childhood," page 25. 

(1) 



g INFANT-FEEDIl 

The mucous membrane of the infant secretes ga 
trie juice which, in general, is similar in properties to 
that of the adult. The amount of secretion in the infant 
is far less than in the adult, while its chemical constitu- 
tion is the same, namely: pepsin, lab-ferment, and acids. 
The exact proportion of the ferment and pepsin has not 
yet been studied sufficiently to admit of any positive 
deductions being made. 

PHYSIOLOGY. 

It is very important to know that the mucous mem- 
brane of the mouth is practically dry at birth; the secre- 
tion of saliva is very small, and, according to Korowin 
and Zweifel, increases toward the end of the second 

month. 

The fermentative (sugar-forming) property of saliva, 
which is trifling at the commencement, increases with the 
quantity of the saliva secreted. This is essentially true 
of other secretions; thus, the pancreatic juice does not 
have the same emulsifying properties in the infant as in 

adults. 

The nursing or sucking centre is located, according 
to experiments made on animals by Basch, in the medulla 
oblongata on the inner side of the corpus restiforme. 

The sucking act is reflex; according to Auerbach, 
the muscles of the tongue participate most actively. 

Acids in the Infant's Stomach. — The gastric contents 
in a nursling contain two acids: (1) hydrochloric acid; 
(2) lactic acid. The. relative acidity is smaller than in 
adults, the highest point being reached one and a half 
hours after nursing. According to von Puteren, the 
acidity is 2 1 / 2 to 3 times as small as in the stomach of 
adults. According to Leo, the acidity of the gastric juice 
of nurslings 1 1 / 2 hours after drinking is only 0.13 per 
cent., whereas, in the adult, after the same time, the 
acidity is from 1.5 to 3.2 per cent. According to Wohl- 
mann, free IiCl can be found in healthy nurslings from 



I \ rRODI OTION". o 

1 V4 to - hours after hiking food. The percentage of 
free 1 1 CI ranges from 0.83 to 1.8 per cent. 

Lactic Acid. — The quantity of lactic acid is, accord- 
ing to Heubner, between 0.1 and 0.4 per cent. 

Pepsin and Hydrochloric Acid. — There are two chief 
functions of the pepsin and hydrochloric acid which are 
the Same in both infant and adult: First, the power of 
killing bacteria: a real bactericidal power. Second, as a 
solvent for albumin. Thus, it is apparent that pathogenic 
micro-organisms that might have entered the stomach can 
be destroyed, although we know the small quantity of 
acid is hardly able to cope with large quantities of food 
contaminated with bacteria. 



CHAPTER II. 

Action of tile Saliva on Various Bacteria. 

Triolo 2 describes a series of interesting experiments 
with saliva. He first irrigated the mouth with bichloride 

or permanganate of potash solution, followed this by 
irrigation with sterilized water until the disinfecting Bub- 
stances were removed, and then inoculated the Burface 
of various culture-media with the sputum. His results 
proved that saliva possesses a distinct bactericidal prop- 
erty, for cultures of five-day-old bacteria were destroyed, 
as well as fresh bacteria eighteen hours old. 

This property, however, was lost when saliva was 
filtered. The saliva of the parotid and submaxillary 
glands, taken singly, were equally efficacious as their 
combined secretion. He believes that the greatest bac- 
tericidal action is due to the secretion of the mucous 
glands in the mouth. 

The Influence of Gastkic Juice on Pathogenic 

Germs. 

Gastric juice is, according to the experiments of Drs. 
Knrlow and Wagner, 3 an exceedingly strong germicidal 
agent, and when living bacilli get into the intestinal canal 
it is due to various conditions entirely independent of the 
gastric juice. When the latter is normal and in full ac- 
tivity, only the most prolific microbes — such as tubercle 
bacilli, the bacilli of anthrax, and perhaps the staphylo- 
cocci — escape its destructive action; all others are de- 
stroyed in less than half an hour. Similar influences exist 



2 Uivista d'Tgiene e di Med. Prat., Neapol. 
"Vrachtj Lancet, March 22, 1890. 

(4) 



[NPLUENOB 01 GASTRIC JUICE. 5 

in the intestines, as proved by inoculation with the cholera 
bacilli. 

Judging from the results of experiments made by 
Zagari, Straus, and Wurtz, who exposed various patho- 
genic organisms, among others that of tuberculosis, to the 
action of gastric juice, we must come to the conclusion 
that, so long as the gastric juice retains a sufficient degree 
of acidity, tuberculosis of the alimentary canal will be 
unlikely to occur. 4 



4 Canadian Practitioner, April 1, 1890. 



CHAPTER II T. 

Stomacii-caiw* II Y. 

At birth the infant's stomach has a capacity of from 
9 to 11 drachms, or 35 to 43 cubic cent i metres. 

At the end of 1 month it is about 2 ounces, or GO 
cubic centimetres. 

At the end of 3 months the gastric capacity is about 
4 times the amount at birth. This very rapid incn 
from birth to this time soon ceases, and the stomach 
capacity grows in size, but at a much slower rate of de- 
velopment. (Baginsky.) 

The series of experiments at the Children's Hospital 
at St. Petersburg, made by Ssnitkin, showed that the 
weight, and not the age, determined the capacity of the 
stomach, and should be used as a guide for the quantity 
of infant-food required. 

If the normal (initial) weight of an infant is 3000 
to 4000 grammes, or about 6.6 to 8.8 pounds, then Vioo 
part, plus the daily increase in weight added, which nor- 
mally amounts to 2 / 3 to 1 ounce, would give the amount 
of food required. 

Biedert also regards the body-weight as an important 
factor in determining the amount of milk to be given, 
but Baginsky argues that, while this rule will hold good 
for a great many infants, he must insist on relying upon 
the scales to show just how much nutriment has been 
digested, and thus a regular system of weighing plus the 
inspection of the stools will aid in establishing the quan- 
tity of food necessary. "There is no unanimity among 
experienced clinical observers upon the subject of infant- 
feeding." Thus, for example, while the great majority 
of clinicians the world over order milk (cows') in vary- 
(C) 



mom LOH-OAPAI n V. 7 

ing dilutions, sonic using the cereals — lite wheat, barley, 

rice, and farina — to dilute and subdivide the curd, other 
clinical observers — Budin and Variot, French observers 
— advise giving infants at birth whole milk; that is, 'pure, 
undiluted cows" milk. 

The following illustrations will serve to show the 
difference in the capacity of infants' stomachs at various 
ages, taken by the author at the morgue of Bellevue Hos- 
pital: — 




Fig. 1. — Infant's Stomach, 1 Month Old. Actual Size. From a 
Case of Malnutrition. Capacity, about 2 Ounces. When 
Stomach was Filled it Held 4 Ounces Easily. (Author's 
Collection.) 



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1M w l-l EEDING. 




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CHAPTEK IV. 

Ferments and Their Actions. 

In newborn children the parotid alone contains ptya- 
lin. The diastasic ferment seems to be developed in the 
sul .maxillary gland and pancreas after two months at the 
earliest. Hence it is not advisable to give starchy foods 
to infants. 

Ptyalin, the diastase of the saliva, a hydrolytic fer- 
ment, or enzyme, of the group of unorganized ferments, 
acts only within a certain range of temperature, being 

-t active at about 40° 0. It acts best in a slightly alka- 
line or neutral medium. Its action is permanently de- 
stroyed by boiling. 

Amylopsin, the diastasic ferment of the pancreatic 
juice, seems to be identical with ptyalin, but it acts much 
more energetically on raw starch, as well as upon boiled 
starch; at the temperature of the body the change is al- 
most instantaneous. At a low temperature this change 
takes place slowly. 

According to Musculus, O' Sullivan, and von Mering, 
ptyalin and amylopsin change starch and glycogen (ani- 
mal starch) into dextrin and maltose. 

Erythrodextrin is first formed, then achroodextrin, 
and, from achroodextrin, maltose. At 40° C. maltose is 
slowly changed into dextrose. (Landois and Stirling.) 

Dextrose and maltose turn the plane of a ray of 
polarized light to the right. The general term grape- 
BUgai was u-ed formerly to include dextrose (glucose) 
and maltose. 

The existence of maltose (though described by Du- 
brunfaut in 1S4T) was for a long time doubted until 

(11) 



12 i \i w l-l EEDINO. 

O'Sullivan, in 1872, confirmed the previous experiments. 

(Foster.) 

In commerce the term "grape-sugar" is applied to 
the solid product of the "grape-sugar works," the liquid 
product being known as "glucose," 

Maltose is the end-product of the action of malt- 
diastase on starch, and can also be formed as an inter- 
im dial e product in the action of dilute sulphuric acid 
on the same substance. It also appears to be the chief 
sugar formed from starch by the diastasic ferments con- 
tained in the saliva (ptyalin) and pancreatic juice (amy- 
lopsin). (Halliburton.) 

The diastasic action of succus entericus, the fluid 
of the small intestine, is incomparably weaker than 
ptyalin or amylopsin, and seems only to continue their 
action. According to SchifT, Busch, Quincke, and Gar- 
land, it does not form maltose from starch (Eichhorst 
states that the juice of the large intestine will do this), 
but changes maltose, which is usually the ulterior prod- 
uct obtained by the action of ptyalin and amylopsin, 
into dextrose. The greater part of the maltose is ab- 
sorbed unchanged. Maltose and dextrose are both 
crystalline. 

Bourquelot thinks that the change from maltose to 
dextrose is due to the action of the intestinal schizo- 
mycetes, and not to the intestinal juice as such, the 
saliva, gastric juice, or invertin. (Landois and Stirling.) 

An important property of dextrose is its power of 
undergoing fermentations. When an aqueous solution 
of dextrose is submitted to the influence of yeast, alco- 
holic fermentation results, yielding alcohol and carbonic 
anhydride. Lactic fermentation occurs in the presence 
of decomposing nitrogenous matter, especially of casein, 
and is probably the result of the action of a specific 
ferment. The first stage is the production of lactic 
acid; in the second, butyric acid is formed, with evolu- 
tion of hydrogen and carbonic anhydride. (Foster.) 



I i:i;m ENTS and THEIB ACTIONS. L3 

Glucose is easily fermentable. (Landoia and Stir- 
ling.) 

The glucoses arc tlic only sugars capable of direct 
fermentation; of these, dextrose is more readily decom- 
posed by yeast than is laevulose. 

Certain other sugars are capable of indirect fermen- 
tation by yeast; among these are cane-sugar and maltose; 
they are first, however, hydrolyzed to glucose. (Jago.) 

Sucrose (cane-sugar) is not readily absorbed by the 
intestinal mucous membrane until it has been transformed 
into glucose. 

(ilucose (like maltose) is taken directly into the cir- 
culation. (Flint.) 

The gastric juice slowly changes cane-sugar into glu- 
cose. 

According to CI. Bernard, invertin in the intestinal 
juice converts cane-sugar into invert-sugar, which is a 
mixture of hevulose and dextrose. (Landois and Stir- 
ling.) 

Dilute acids convert cane-sugar into invert-sugar, 
which consists of equal parts of dextrose and laevulose. 

"When subjected to the action of ferments, cane-sugar 
is first transformed into invert-sugar, then into alcohol 
and carbonic acid (vinous fermentation). (Battershall.) 

Succus entericus has been said to change cane-sugar 
into grape-sugar and by a fermentative action to convert 
cane-sugar into lactic acid, and this again into butyric 
acid, with the evolution of carbonic acid and free hydro- 
gen. (Foster.) 

Laevulose is isomeric with dextrose, but it turns the 
plane of a ray of polarized light to the left; it is non- 
crystallizable and ferments witli difficulty. (Landois and 
Stirling.) 

Lactose, when isolated, is incapable of direct alcoholic 
fermentation, but milk itself may be fermented. Lactose, 
however, is directly capable of undergoing lactic and 
butyric fermentation. (Foster.) 



14 INFANT-] BED! 

The theory — which a few years ago was accepted — 
that carbohydrates, to be absorbed, must be in the form 

of glucose is now known to be wrong. 

Lactose and maltose are absorbed without change, and 
probably some of the dextrins. (Koberl 

Lactose is a readily soluble and diffusible body, and, 

by virtue of these properties, does not require to und< 
chance within the alimentary canal to be rendered lit for 
absorption. (Pavy.) 



CHAPTER V. 

A I. Ill' MIX AM) THE GaSTEIO JuiCE. 

Anotheb property of gastric juice in infants is tlic 
transformation of albumin in the following manner: (1) 
albumose; (2) then peptone; (3) and lastly syntonin. It 
is thus apparent that, although the infantile stomach plays 
a subordinate rule as a nourishing organ, it cannot he 
denied that fluid substances — like water, a solution of 
salt, and solution of sugar — are absorbed, and in a less 

no albumin also. The relative size and capacity of 
the stomach prevent the function from being as thor- 
ghly developed as in the adult. 

Length of Intestine. 

The relative length of the intestine in nurslings is 
greater than in adults; so that the intestine is six times 
long as the body. Forster believes this is one reason 
why nurslings receive more nourishment from milk than 
do adults. The small intestine develops during the first 
two months of life more than the large intestine, and after 
the second month the reverse is true. The duodenum 
remains relatively the longer until the end of the fourth 
month. The transverse colon is the widest and most elas- 
tic portion of the large intestine. The continuation of 
the large intestine in infants into the rectum is indicated 
by a narrowing at this point. 

The relative length of the large to the small intestine 
d by Frolowsky to be, in the newborn, 1 to G; in 
nurslings, 1 to 5; in adults, 1 to 4. 

Formation of Gas in the Intestine. 

When we consider the lesser development of the mus- 
of the intestine, we can readily understand that peri- 

(15) 



16 I \ I \\ i-l-l. l.Di SQ, 

stall i<* movements are more irregular and less forcible, 
and thai the muscles possess Less tone; on this account, 
there is a larger amount of gas contained in Hi'- intestine^ 
which constantly distends if. Thus L1 Is apparent why the 
abdomen always appears larger in the infant in propor- 
tion to the other parts of the body. 

Action of Intestihtal Muscles. 

The action of the intestinal muscles is chiefly to trans- 
port the food by a series of peristaltic movements. Parts 
of the intestine are active, while others remain passive. 
Heubner maintains that post-mortem examinations never 
show all parts of the intestine in the same condition, owing 
to the irregularity of the muscular movement. 

Development of Glandular System. 

The development of the glandular system in infants 
is very poor, whereas the lymphoid tissues, follicles, are 
comparatively well developed. 

Lieberkiihn's glands are fewer in number than in 
adults, whereas the Brunner glands in the duodenum are 
numerous and well developed. 

The Secretory and Absorbing Power of the 
Epithelium and the Glands. 

Heubner maintains that the secretion takes place from 
cells, located in the small intestine, which are scattered 
about and are few in number, whereas in the large intes- 
tine they are far more numerous. 

Absorption of Fat. 

The absorption of fat takes place through the intes- 
tinal epithelium in the duodenum and jejunum; the 
glands also participate in this action. According to the 
histological investigations by Baginsky, the real absorbing 
system of the intestinal wall is found in the connective- 



ABSORPTION OF FAT. 17 

tissue bodies of the mucous membrane of the infantile 

intestine, in which arc located lymphatic vessels con- 
nected with the larger lymph-channels of the intestine. 
The physiological and chemical functions are much less 
developed in infants than in adidts because the intestinal 
glands are relatively less developed. 



CHAPTEE VI. 

Livi :u am) Bile en Nubslii 

The liver in nurslings is relatively larger than in 

adults. 

The quantity of bile in the gall-bladder is \ - aalL 

It is of a golden-yellow color, and has a neutral n 
Its specific gravity varies from 1.014 to 1.053. Ac ord- 
ing to Baginsky, the Idle in nursling tnic 

salts, — cholesterin and lecithin, — fat, and various a 
in less proportion than in adults. Baginsky was abl< 
demonstrate the presence of glycocholic acid. The } 
ence of a much less quantity of the bile-acids in the in- 
fant is a beneficial physiological condition. Tor it is 
a well-known fact that these acids inhibit the digestive 
action of the pepsin and of the pancreatic juice. An- 
other point is that the absence of a bile-acid prevents 
the assimilation of large quantities of fat, as it is im- 
possible to split up the fat into fatty acid and glycerin. 
Thus, fermentative processes are much more frequent 
in nurslings and appear with greater intensity than in 
the adult, because of the absence of the biliary acids. 
The amylacea and all substances containing flour are — 
owing to the above-described condition of the pancreatic 
juice and the bile — not fit substances to give the infant, 
especially during its first three months of life, although 
very small quantities can be digested, and after the fourth 
month are not only digested, but also absorbed. Bagin- 
sky and Sommerfeld found large quantities of mucin in 
the bile. 

Unorganized Ferments. 

The unorganized ferments seem to be nitrogenous 
bodies; their exact composition is unknown, and it is 
doubtful if they have ever been obtained perfectly pure. 
(Landois and Stirling.) 

(15 



i \oi;i; an i/.i:d ii:i;m ENT8. 



19 



Table Showing the Unorganized Ferments Pbesent in the 
Body and Their Actions. 



1'i.riD or Tissues. 


Kkkmknt. 


Actions. 


Saliva. 


1. 


rtyalin. 


Converts starch chiefly 
into maltose. 




1. 


Pepsin. 


Converts proteids into 
peptones in an acid me- 
dium, certain by-prod- 
ucts being formed. 


Gastric juice. 


2. 


Milk-curdling. 


Curdles casein of milk. 




3. 


Lactic-acid fer- 


Splits up milk-sugar into 






ment. 


lactic acid. 




4. 


Fat-splitting. 


Splits up fats into glyc- 
erin and fatty acids. 




1. 


Diastasic, or 


Converts starch chiefly 






amylopsin. 


into maltose. 




2. 


Trypsin. 


Changes proteids into pep- 
tones in an alkaline 


Pancreatic juice. 






medium, certain by- 






products being formed. 




3. 


Emulsive (?). 


Emulsifies fats. 




4. 


Fat-splitting, or 


Splits fats into glycerin 






steapsin. 


and fatty acids. 




5. 


Milk-curdling. 


Curdles casein of milk. 




1. 


Diastasic. 


Does not form maltose, 
but maltose is cbanged 
into glucose. 


Intestinal juice. 


2. 


Proteolytic. 


Fibrin into peptone (?). 




3. 


Invertin. 


Changes cane-sugar into 

grape-su^ar. 




4. 


Milk-curdling. 


In small intestine (?). 


Blood. 








Chyle. 








Liver (?). 


Di-.stasic ferments. 




Milk. 








Most tissues. 








Muscle. 


Pepsin and other fer- 




Urine. 




ments. 




Blood. 


Fibrin-forming fer- 








ment. 





SO tNFANT-FEEDl 

Organized Ferments, 

Yeast is the type of the living, or organized, fer- 
ments. 

Other living ferments, schizomycetes, seem to be pro- 
duced from the numerous fungi introduced into the in- 
testinal canal with the food and drink. (Landois and 
Stirling.) 

The action of these organized ferments is now as- 
cribed to certain minute microscopic organism?; when the 
result is the production of some useful body the change 
is termed "fermentation," and "putrefaction" when the 
products are useless and offensive. 

Briefly stated, a liquid free from ferment-organisms 
or their germs does not undergo fermentation. (Jago.) 

The lactic fermentation and putrid or butyric fer- 
mentation of milk are both due to mysteriously minute 
bacteroid bodies. (Blyth.) 

The fungi which occur everywhere in the atmosphere 
are the cause of the spontaneous acidification and subse- 
quent coagulation of milk. (Landois and Stirling.) 

The fermentation of carbohydrates, fats, and proteids 
is believed to be caused by these micro-organisms. 

Each particular organism has its special product of 
fermentation. (Jago.) 

Hydrolytic Agents. 

These bodies include oxalic and dilute hydrochloric 
and sulphuric acids. 

Commencing with soluble starch, these acids po- 
the power of converting the body first into dextrin and 
maltose, and then into glucose. 

The acid hydrolytics also transform cane-sugar into 
glucose. 

There is another most important group of hydrolyz- 
ing agents; these consist of certain soluble bodies of 
organic origin, and among them may be mentioned hu- 



ABSORPTION. 2 I 

mas saliva, filtered aqueous infusion of yeast, flour, bran, 
an<l malt. 

The following name- have been given to active prin- 
ciples of these hydrolytics: — 

Name of Hydrolyzing 
Substance. Constituent. 

Human sali\a. Ptyalin. 

Yeast. Zymose, or invertin. 

Flour and bran, especially 

the latter. Cerealin. 

Malt. Diastase. (Jago.) 

Absorptiox. 

As most substances in the state in which they are 
used for food are either insoluble or diffuse but imper- 
fectly through membranes, complicated digestive proc- 

- render these substances soluble and diffusible, and 
thus tit them for absorption; most of the fats are emul- 
aionized. The mucous membrane of the intestinal tract 
from the cardiac orifice of the stomach to the anus is 
adapted for absorption. In the stomach, watery solutions 
of Baits, grape-sugar, maltose, peptone, and poisons, espe- 
cially alcoholic solutions of poisons, are absorbed. The 
empty stomach absorbs more rapidly than one filled with 
food. Gastric catarrh delays absorption. The greatest 
area of absorption is undoubtedly the small intestine. 
(Landois and Stirling.) 

Table of the More Important Carbohydrates and 
Their Formulae. 

Cellulose C (i H in 5 . 

Starch C H lo O 5 or n(C,H 10 O 5 ). 

Dextrin C 6 H 10 O 5 . 

Maltose C^H^Ou or C 12 H, 2 O n + H 2 0. 

Dextrose (glucose, grape-sugar) C 6 H 12 O a or C, -f H 12 H 2 0. 

Sucrose (saccharose, cane-sugar) C 12 H 22 O n . 

Laevulose C 8 H 12 6 . 

Invert-sugar C 6 H 12 O a . 

Lactose (milk-sugar) C^H^O,, or C„H, 2 O u -f H 2 0. 



6A I \l LNT-FBBDING. 

The sugars are classified into three groups, as given below, with 
their important members: — 

(A) Saccharoids (non-fermentable Bugars): — 

Mannite (from manna) C 6 H u 8 . 

Dulcite C,H 14 O e . 

(B) Glucoses: — 

Dextrose (grape-sugar, starch-sugar) C H 12 O 8 -f- Aq. 

Lsevulose (honey) C H 12 O a . 

(C) Saccharoses: — 

Sucrose (cane-sugar) C^H^Ou -f- Aq. 

Maltose (malt-sugar) C^H^Ou + Aq. 

Lactose (milk-sugar) C 12 H220 U + Aq. 

Cellulose. 

Cellulose acts mainly as a sort of connective tissue 
constituting the framework of vegetable organisms. 

Enzymes. 

The enzymes, hydrolytic or organic ferments, act only 
in the presence of water; they are most active betwe-'-n 
30° and 35° C, and are destroyed by boiling. (Landois 
and Stirling.) 

Hydrolysis. 

The changes which carbohydrates undergo have been 
called by the general name of hydrolysis. (Jago.) 

Hydrolysis, when affected by diastase or its congeners, 
is termed diastasic action, or diastasis. 

The ultimate products of diastasis of starch are sugars 
of various kinds; the process of conversion is frequently 
termed the saccharification of starch. 

Soluble Starch. 

Researches of Brown, Heron, and others make it 
probable that the formula of starch is more complex 
than usually expressed by C 6 H 10 O 5 , and the formula 
n(C e TT 10 O 3 ) is now used, n expressing the unknown. 



ACTION OF M U-T-m VSTASE. 






able starch Lb expressed by the formula n(0 12 H 20 - 
O 10 ). 

Kaw starch is insoluble in cold water, and cannot be 
dissolved by any known Liquid without change, it having 
a definite organic structure, an outer envelope of cellulose 
inclosing the starch proper (amylose, or granulose). 

The cellulose envelopes may be ruptured by mechan- 
ical means or by boiling in water; in the latter case the 
containing cellulose bursts, from the interior particles 

lling, and the amylose dissolves in the water, forming 
a viscous liquid (gelatinization). 

A solution of starch (soluble starch) is colorless, odor- 
It as, and tasteless, but is colored an intense blue by the 
addition of iodine in extremely small quantities. (Jago.) 

Dextrin is very soluble in water; it can be prepared 
from starch by action of heat maintained at a tempera- 
ture of about 150° C. 

Starch, boiled with dilute sulphuric acid, will be con- 
verted into dextrin and maltose, and by continued boiling 
most of the dextrin and maltose is transformed into glu- 
cose (dextrose). 

Action of Malt-diastase. 

The action of malt-diastase on a solution of starch in 
water at temperatures from 15° C. to about 70° C. more 
or less rapidly hydrolyzes the starch into a mixture of dex- 
trin and maltose. The longer the operation is continued, 
the higher is the proportion of maltose produced; but 
even prolonged boiling does not result in any further 
hydrolysis of the maltose into glucose. 

Unlike the acids, malt-diastase is incapable of con- 
verting starch further than into dextrin and maltose. 
(Jago.) 

Brown and Heron's results lead to the opinion that 
there are several dextrins. And these dextrins are di- 
vided into two groups: erythrodextrins, those first forms; 
and achroodextrins (reducing dextrins). They also think 



2 1 1MWNT-] EEDING. 

that there is an intermediate body between dextrin and 
maltose which they call maltodextrin. 

According to Musculus and Gruber, erythrodextrin 

is a mixture of dextrin and soluble starch. 

Dextrin does not undergo alcoholic fermentation; bnt, 

after dextrose is formed from it, the dextrose is capable 
of directly undergoing vinous fermentation. (Foster, 
Battershall.) 



CHAPTER VII. 

Fat. 

Fat contained in milk is no simple compound. It 
consists of at least nine compounds. More fat is found 
in colostrum, in evening milk, and in the upper layers of 
a pail or bowl of milk. Its average percentage is 4.3 per 
cent.: a great deal more than in human milk. For this 
reason Jacobi 5 has always taught that "it is better to 
reduce the fat to be given to infants than to increase it." 

The deficiency of butter does, however, seriously im- 
pair the nutritive value of the milk. 

When there is not enough butter in the milk the 
casein present is digested with more difficulty, and the 
result is the same as if the casein were in excess. 

The plastic (building) materials of food cannot be 
converted into the tissues of the body without the pres- 
ence of fat. Fat seems to be essential to the formation 
of new cells, whose nucleoli always contain fat, and there 
is more in young and rapidly growing tissues than in those 
whose growth has been slackened by maturity. From this 
is evident the immense importance of fat in the nutrition 
of the rapidly growing infant-body. 

Sugar. 

The effects when the amount of sugar is insufficient 
will be partly the same as when butter is deficient, for 
the reason that sugar partly supplies the place of butter 
and partly is converted into fat. 

Other substances that result from the decomposition 
of sugar are of importance in many ways. Lactic acid is 



5 A. Jacobi, "Intestinal Diseases of Infancy and Childhood," 
page 87. 

(85) 



2G [NFANT-PBBDING. 

formed in the stomach, helps to give acidity to the gastric 
juice, and thus assists in the digestion of casein. 

Milk in which sugar is deficient frequently becomes 
a source of constipation in t lie child. (Jacobi.) 

Carbohydrates. 

This name is given to a class of compounds contain- 
ing six, or some multiple of six, atoms of carbon united 
with hydrogen and oxygen, the latter two in the same 
proportion as in water, H 2 0; for illustration, the carbo- 
hydrate, starch, is expressed by (C 6 H 10 O 5 )n (simplest for- 
mula). 

Hydrocarbons. 

Numerous compounds of carbon with hydrogen are 
classed under the general name of hydrocarbons; the 
generic formula CnH 2 n + 2 is applied to such hydrocar- 
bons as petroleum, marsh-gas, and oils formed by the dry 
distillation of coal, wood, etc. (turpentine, etc.). 

Fats. 

In chemical constitution fats consist of the ethers of 
the higher fatty acids. 

Butyrin, or butter-fat, has the formula C 2 H 5 (C 4 - 
H 7 2 ) 8 . 

Lard contains palmitin [C 3 H 5 (C 16 II 31 2 )3] and 
stearin [C 3 H 5 (C 18 H 35 C 2 ) a ]. 

Castor-oil contains ricinolein [CsIL^CjsILjoOs^] and 
palmitin (as above). 

The constitution of many fats and fixed oils is unde- 
termined. 

Another source of fat is its formation from albu- 
minous bodies. (Landois and Stirling.) 

While nitrogenous matter is mainly devoted to tissue- 
formation, the non-nitrogenous alimentary principles — 
the fats and the carbohydrates — supply the source of 
power, — are appropriated to force-productions. 



PATS. "-'■ 

The term "hydrocarbons" has been applied by many 
writers to Eal 

The fata are a class by themselves. The hydrocar- 
bons are marsh-gas, benzin and its homologues, and re- 
Bemble the fats in many ways, bnt exhibit decided pecul- 
iarities, which mark them as a distinct group. 

The fats have the general formula of C 10 H ls O. 

Fats are easily oxidized, yielding heat chiefly, and 
belong, therefore, to the calorifacient group. 

There is every reason to believe, however, that fat 
is essential to tissue-development, as it seems to be in- 
trinsically mixed up with nitrogenized matter in the ani- 
mal tissues. 

Though fats cannot, per se, supply what is required 
for tissue-development, they, nevertheless, take part in 
the process. (Pavy.) 

Fat is absorbed in the form of an emulsion produced 
by the action of the bile and pancreatic juice; the villi 
of the small intestine are the chief absorbents, but the 
epithelium of the stomach and that of the large intestine 
also take a part. (Landois and Stirling.) 

The fats and the carbohydrates seem to be quite 
closely allied. 

Part of the fat of the body is derived directly from 
the fat of the food, and it is absorbed and deposited in 
the tissues. 

According to V. Voit, no fat is formed in the body 
directly from carbohydrates. 

Lawes and Gilbert, ITeiden and V. Wolff arrived at 
the conclusion that the carbohydrates absorbed are di- 

t/ 

rectly concerned in the formation of fats. We must as- 
sume that the carbohydrates are consumed or oxidized in 
the body and that thereby a non-nitrogenous body derived 
from the proteids is prevented from being burned up, and 
that it is changed into fat and stored up as such. Xo 
doubt, fat is formed indirectly in the blood in this way. 
(Landois and Stirling.) 



I\r \\T-l EEDIKO. 

The balance of evidence Beems to be in favor of the 
view thai carbohydrates may be in -nine way directly con- 
verted into fat. 

The characteristic feature of proteid food is that it 
increases the oxidative, metabolic activity of the tissues. 
Leading to a rapid consumption, not only of itself, but of 
non-nitrogenous food as well. 

One value of fats and carbohydrates lies in their being 
sources of energy, more than three-quarters of the normal 
income of potential energy coming from them; they are 
ultimate sources of muscular energy as well as of heat. 
Their great characteristic is, however, that they do not, 
like proteid food, excite the metabolic activity of the 
body, and, therefore, instead of giving rise to bodies 
demanding immediate excretion from the system, they 
can deposit their metabolic products as apparently little 
altered, but in reality greatly changed, fat. (Foster.) 

Chloride of Sodium (Table-salt). 

If the chlorides in the blood produce hydrochloric 
acid, then their necessity is apparent. All infants should, 
therefore, receive a sufficient quantity of table-salt with 
each feeding. Brucke states that salt is transformed by 
electrolvsis into hvdrochloric acid. 6 

Salts. 

The several saline matters, including the extractives 
of animal and vegetable food, are no less essential ele- 
ments of a diet than proteids, fats, or carbohydrates, by 
reason of their regulating the energy of foodstuffs, more 
strictly called. They are necessary to life; the body in 
their absence fails to carry out its usual metabolism, and 
disease, if not death, follow-. 



6 Hammersten, "Physiological Chemistry of Digestion." page 
1S5. first edition. 



BALT8 Wl> WA ill;. 

The Baits musl have important functions in directing 
the metabolism of the body. The striking distribution of 
them in the tissues, the preponderance of sodium chlo- 
rides in blood-serum and of potassium phosphates in the 
red corpuscles, must have Borne meaning, though we are 
in the dark concerning it. 

Salts and Water, 

The element phosphorus seems no less important than 
carl Min or nitrogen; the element sulphur, again, is only 
second to phosphorus, and is a constituent of nearly all 
proteids. 

We know that the various saline matters are essen- 
tial to health; that when they are not present in proper 
proportions nutrition is affected; that the properties and 
reaction of various proteid substances are closely depend- 
ent on the presence of certain salts; but beyond this we 
know very little. 

Last, water has an effect on metabolism, as shown by 
the fact that, when the water of a diet is increased, the 
urea is augmented to an extent beyond that which can be 
explained by the increase of fluid augmenting the facili- 
ties of mere excretion. (Foster.) 

Albumixous, or Proteid, Sebstaxces. 

The proteids form a large group of closely related 
substances, all of which are, perhaps, modifications of the 
>ame body. The infant manufactures most of the pro- 
teid- of ir- ever-growing bodv from the casein of milk. 
Their chemical constitution is quite unknown. Some are 
soluble, others insoluble, in water. The most important 
mtrogenized principles used as food are musculin, albu- 
min, casein, fibrin, gelatin, and gluten. The product of 
the digestion of such principles in the stomach was called, 
by Mialhe, albuminose; afterward, by Lehmann, pep- 
tones. This change renders them not easily coagulable 



30 INFANT-FEEDING. 

and endosmotic, so that they pass through membranes 
with facility and are readily assimilated after their ab- 
sorption. (Flint.) 

Nitrogenous alimentary matter may be said to serve 
principally for the development and renovation of the 
living tissues. 

As to the production of a fat as a result of the split- 
ting up of nitrogenous matter, it is highly probable that 
such production takes place, but anything in the nature 
of proof of this is wanting. 

The nitrogenous compounds are mainly "histoge- 
netic," or tissue-forming, materials, but, by the sepa- 
ration of urea which occurs in their metamorphosis in 
the animal system, an hydrocarbonaceous compound is 
left, which may be appropriated to heat-production. 
(Pavy.) 

The nitrogenous bodies of milk are not thoroughly 
understood, and are too frequently classed under one 
head : proteids. 

For about five days after calving colostrum is secreted 
by the mammary glands. This colostrum is poor in fat 
and sugar, but rich in proteids, which vary between 15 
and 20 per cent. These proteid bodies are not well un- 
derstood, but albumin is about two-thirds of the total 
quantity. Casein is also present. Colostrum is curdled 
by rennet, but not as easily as milk. It is interesting 
to note here that, for commercial purposes, the stomach 
of a calf under four days old is practically worthless for 
furnishing rennet. It is well known that large quantities 
of albumin are absorbed without peptonization; so it 
would be seen that Nature intended to furnish a very 
digestible food for the first few days of life. By the fifth 
or sixth day normal milk is secreted, the change from 
colostrum to milk being gradual, the quantity of albumin 
decreasing until in the normal milk it runs about 0.4 per 
cent. When the secretion ceases to coagulate on boiling, 
it is considered milk. 



PEOTEIDS. 31 



Proteids. 



The division, by Baginsky, of the various component 
parts of milk into fat, carbohydrate, albumin, casein, salts, 
and water gives a clearer insight into the vital necessities 
of a growing infant. We have adopted this division from 
a clinical standpoint, because frequently a chemical re- 
port of an examination of breast-milk will show deficient 
proteids," and hardly convey to the unskilled which vital 
element is lacking. 

If, however, deficient albumin and casein were noted, 
instead of combining the two as one element and 
calling them proteids, then raw albumin, as the white 
of egg or yolk of egg, would suggest themselves to 
remedy the element found wanting. I shall, there- 
fore, speak of "deficient albuminoids" and "deficiency in 
casein" rather than combine these elements under the 
one heading of proteids, which is now being used by so 
many text-books. 

A Clixical Method for the Estimation of 
Bee ast-milk Peoteids. 7 

"Two 'milk-burettes,' each containing 5 cubic centi- 
metres of milk, are subjected to a temperature warm 
enough rapidly to sour the milk, and are allowed to re- 
main in this warmth until a distinct precipitation can be 
seen. The burettes are then cooled in water, the milk- 
serum is withdrawn into the graduated tubes, 10 cubic 
centimetres of Esbach's solution (picric acid, 5 grammes; 
citric acid, 10 grammes; water, 500 cubic centimetres) 
are added, the tubes are shaken and centrifugated until 
constant reading, and the resulting precipitate is read. 
This reading expresses in percentage the amount of total 
proteids in the milk. 



7 Reprinted in large part from George Woodward's article in the 
Philadelphia Medical Journal. May 21, 189S. 



6 I 



[NFANT-FEEDING. 



"Such is a bare statement of the method. I will 
briefly take up the various steps in detail. The 'milk- 
burettes' arc made of about 10 cubic centimetres' capacity, 

iind have a glass pinch-cock or valve and a narrow exit- 
tube about one inch long (Fig. 8). I have tried various 
forms of burettes and separating funnels, and find this 
the most satisfactory. A temperature of from 95° F. to 
100° F. is the most rapidly effective to produce fermen- 
tation. This I have conveniently obtained by placing the 
tubes in a burette-stand and the stand in contact with a 
radiator. The time required to obtain a distinct precipi- 
tation of casein is from eighteen to twenty-four hours. 




Fig. 8. — Woodward's Burette for Estimating Proteids. 



At the end of this time the milk has distinctly separated 
into an upper layer of viscid yellow fat; a lower layer 
of fluid milk, quite opaque above, almost translucent be- 
low; and, clinging to the sides of the tube, and especially 
at the bottom, a granular precipitate. The cooling of the 
milk increases the viscidity of the fat and facilitates its 
separation from the milk-serum. The milk-serum is re- 
ceived into 15-cubic-centimetre graduated tubes, the solu- 
tion of picric and citric acids added up to the 15-cubic- 
ccntimetre mark, the mixture stirred with a glass rod and 
placed in the hand-centrifuge. The amount of centrif liga- 
tion required is in direct proportion to the care used in 
separating the fat. If fermentation be watched and the 



LIME-SALTS IN COWs' MILK. 33 

separation be made as soon as the casein-precipitate is dis- 
tinctly present, the centrifugation to a constant reading 
may be quickly accomplished." 

LlME-SALTS IN Cows' MlLK. 

Milk curdles under two entirely distinct sets of con- 
ditions: (1) it curdles on addition of an acid and (2) it 
curdles under the influence of rennet (when the reaction 
of the milk is either neutral or slightly acid). The two 
varieties of curd which are obtained under these circum- 
stances may be denominated "acid curds" and "rennet 
curds," respectively. Acid curds must inevitably be 
formed in the stomach after milk has been drunk, if the 
gastric contents are allowed to become acid. Such curds 
(we are familiar with them in ordinary life in the form, 
for instance, of cream cheese or sour milk) are probably 
not sufficiently firm to set up digestive disturbances. On 
the other hand, rennet curds (such as we are familiar 
with in the form of renneted milk and of ordinary cheese) 
may be extremely firm. It is, therefore, in all probability 
these rennet curds which set up the familiar infantile 
dyspepsia of bottle-fed children. If this is so, the facts 
elicited by Arthus and Pages would appear to be of domi- 
nating importance in the treatment of these dyspeptic 
conditions. In order to appreciate this correctly the fol- 
lowing facts must be attended to: (1) rennet-coagulation 
is delayed and curdling becomes less and less firm as 
an increasing proportion of the lime-salts of the milk 
becomes precipitated as insoluble salts (Arthus and 
Pages); (2) addition of soluble lime-salts (up to a certain 
maximum) causes increased rapidity of rennet-coagula- 
tion, accompanied by increased firmness of clot (Arthus 
and Pages); (3) human milk contains 0.03 per cent, of 
lime (Bunge); (4) cows' milk contains 0.17 per cent, of 
lime (Bunge). (Lancet.) 



34 infant-feeding. 

Lime-water and Milk. 

Dr. Brunn 8 finds the use of lime-water as an addition 
to milk a frequent cause of constipation and consequent 
fissures of the anus in children. Any cause which pro- 
duces diarrhoea, with following constipation, will cause it. 
Constipation, proctitis, and severe pains on defecation are 
the results of a fissure. Hernia and masturbation are 
possible consequences. The condition may be long-last- 
ing, although it is easily discovered when attention is 
called to it. He treats it by regulating the diet, by clean- 
liness, irrigation of the rectum, and by dilation of the 
sphincter ani, which is easily done. 

Bicarbonate of Soda in Milk. 

The addition of the bicarbonate of soda to milk for 
its preservation has hitherto been tolerated by the police, 
but the Council of Hygiene of the Seine has condemned 
the practice, as it is not free from danger. The trans- 
formation of the sugar of milk into lactic acid gives rise, 
in milk so adulterated, to a lactate of soda, which is purga- 
tive, and is thus a cause of diarrhoea in young children. 
Under these conditions the Council considers that the 
addition of the bicarbonate of soda to milk, which is an 
aliment of the first order and very often prescribed for 
invalids and children, should neither be authorized nor 
tolerated. 9 

Soda is also added to milk sometimes to delay the 
souring process. The prohibition of this chemical may be 
viewed in the light of a stultification when we consider 
the large amount of bicarbonate of soda that is used at 
the present day in one of the popular methods of feeding 



8 Hospitals-tidende, R. 3, B. 8, S. 1089; Medical and Surgical 
Reporter, February 13, 1892, page 277. 

8 Lancet (London), February 11, 1888. 



MILK-SUGAR. 35 

infants. I think it is no less reprehensible on the part 
of the phvsician than it is on the part of the dairyman. 10 

Milk-sugar. 

Process of Making. — The milk is collected and al- 
lowed to stand for several hours in cooling vats; then it 
is conveyed to a large tank, to be coagulated. Various 
substances are used to hasten the coagulation. According 
to Flint, 11 vinegar, cream of tartar, muriatic acid, and 
sour milk can be used to produce coagulation, but, of 
course, rennet is the most popular and most commonly 
used agent. This, as we all know, is the fourth stomach 
of the calf. The directions given for preparing rennet 
are as follow: "Care must be taken not to use too much 
water in cleaning; wiping lightly with a moistened cloth 
until it is clean is the better way. If then blown up like 
a bladder and hung up and dried, it will retain its power 
for coagulating milk for years." Pieces of this rennet are 
steeped in warm water, and the solution from it is added 
to the milk and then the milk is raised to a temperature 
above 100° and kept at that until coagulation takes place. 
Then the whey is drawn off, and this whey is evaporated 
by boiling to one-fifteenth of its original mass. This 
i- dipped out into a tub, where the sugar will crystallize 
in twenty-four to forty-eight hours. These crystals are 
known as "sand"; this sand is put into sacks, from which 
the water drains off. The sand is again boiled in water 
to a sufficient concentration, and the sugar is allowed to 
crystallize in sticks. It will thus be seen that many of 
the other crystallizable bodies contained in milk would be 
included in this crystallization, as well as the alkaloids 
or ptomaines. 



10 E. E. Brush, M JO., in the Journal of the American Medical 
Association, November 23, 1889. 

11 "Milk-cows and Dairy-farming." 



'36 INFANT-FEEDING. 

The use of milk-sugar lias increased notably during 
the last few years, in the feeding of children, through the 
recommendations of Soxhlet and Reubner. It is not gen- 
erally known, however, that under some circumstances the 
milk-sugar of cheaper sorts may be contaminated by the 
presence of bacteria, derived from the milk from which 
it is made. In repeated examinations the author has 
found a large number of bacteria, and among them those 
which lead to the formation of gas: a form particularly 
feared because of its power to decompose milk. If such 
milk-sugar be added to sterilized milk it quickly curdles 
it; if, also, a small quantity of such sugar be added to a 
sterile milk, and subjected to the usual sterilizing methods 
for twenty or even forty minutes it is not as certainly 
rendered free from germs as is the case with ordinary 
milk. Enough germs, howei^er, are destroyed so that the 
milk will not spoil until the second or third day. With 
the Soxhlet method of preparing the milk it was found 
that a very impure milk-sugar could be used without 
harm, provided the milk was used up within twenty-four 
hours. It was quite another matter when, as the author 
found, certain venders of sterilized milk added the pow- 
dered sugar after the sterilization process. Through the 
addition of the impure milk-sugar, countless germs were 
introduced into the sterile milk, and, since the milk is 
only slightly warmed before feeding, they enter the ali- 
mentary canal of the child, where they may produce the 
very evils one has sought to avoid. Under such circum- 
stances the use of the relatively sterile beet- or cane- sugar 
is preferable. From this is derived the practical rule that 
cheap grades of milk-sugar should be avoided in the prep- 
aration of the food of infants, or at least that thev should 
be used only before a careful sterilization of the milk. 
(H. Neumann. 12 ) 



12 Berliner klinische Wochenschrift; American Medico-Surgical 
Bulletin. 



MILK-SUGAR. 37 

Dr. E. E. Brush, 13 of Mount Vernon, K Y., says that 
"one of the faults of physiological chemists is that they 
make no distinction between a substance existing in a 
natural condition and that substance eliminated and iso- 
lated by chemical means. Thus, the sugar of milk of 
commerce and the sugar of milk as it exists in that fluid 
are regarded by the chemists as one and the same thing. 
Hence, the physician has been led into the error of think- 
ing that as the sugar in milk is that designed by nature 
as the best saccharine nutrient, therefore the isolated 
sugar must fulfill the same function. This is not the 
truth. Sugar of milk in that fluid is all assimilated, and 
the milk-sugar of commerce, when added to baby food, is 
eliminated both by the kidneys and bowels. This I have 
demonstrated by numerous experiments. I have never 
found sugar present in the urine or fseces of babies fed at 
the breast. On the other hand, in three cases of infants 
fed in twenty-four hours with 3 ounces or more of mix- 
tures containing commercial milk-sugar (as in Meig's 
mixture), I have always found sugar in the urine and 
faeces, demonstrated by Fehling's test.' 7 

Impurities in Milk-sugar. — J. O. Braithwaite 14 states 
that the new United States Pharmacopoeia methods of 
testing milk-sugar do not suffice, because they consider 
only the contents in grape-sugar and cane-sugar. He 
found in a great number of samples a disproportionately 
high residue of ash, which coagulates milk when the latter 
is heated to nearly the boiling-point. This is a serious 
defect, since milk-sugar serves now mainly as a material 
for preparing artificial food for infants. The author 
found the ash, in several samples, to consist chiefly of 
magnesium; he found lime in one sample; and concludes 
that, during the preparation of the sugar, magnesium 
carbonate and lime had been used for neutralizing the 



18 Journal of the American Medical Association, July 5, 1890. 
14 London Pharm. Journal, April 14, 1894. 



38 [NFANT-FEEDING. 

acid solution, and that, during crystallization, magnesium 
lactate had crystallized out with the milk-sugar. The 
author confirmed, by way of experiments, the well-known 
fact that many metallic and earthy salts coagulate milk, 
and that magnesium lactate does so also, even in milk- 
sugar to which 0.5 per cent, of the salt had been admixed. 
He suggests that the pharmacopoeias restrict the amount 
of ash from milk-sugar to 0.25 per cent, as a maximum. 
Bacteria in Milk-sugar. — Prof. Albert R. Leeds 15 
states that all the samples of pulverized milk-sugar com- 
ing from drug-stores and which he had examined gave an 
abundant crop of bacteria when definite weights dissolved 
in sterilized water were submitted to ordinary gelatin- 
peptone culture; and the presence of bacteria as a com- 
mon impurity in lactose, to be looked for and avoided 
by the chemist and the druggist, was sufficiently demon- 
strated. 



15 Journal of the American Chemical Society; Oil, Paint, and 
Drug Reporter, August 31, 1S96. 






CHAPTER VEIL 

Bacteria of the Intestine. 

There are a great many bacteria found in the intes- 
tine. These are present in a normal infant, as well as in 
an infant suffering from a gastro-intestinal disorder. A 
great many of these bacteria are, therefore, non-patho- 
genic. Miller, who carefully studied the various micro- 
organisms in the mouth, found that most of them could 
again be found in the intestinal canal. He also found 
that certain germs possessed diastasic properties, and were 
capable of producing lactic-acid fermentation in the milk- 
faeces of nurslings. 

Escherich found two germs, the one he called a bac- 
terium lactis aerogenes (or bacterium aceticum, Bagin- 
sky)" and the other the bacterium coli commune. In the 
meconium he found proteus vulgaris, streptococcus coli 
gracilis, and bacillus subtilis. 

BACTERIUM COLI COMMUNE (eSCHERICh). 

Obtained by Emmerich (1885) from the blood, vari- 
ous organs, and the alvine discharges of cholera patients 
at Naples; by Weisser (1886) from normal and abnormal 
human faeces, from the air, and from putrefying infu- 
sions; by Escherich (1886) from the faeces of healthy 
children; since shown to be constantly present in the 
alvine discharges of healthy men, and probably of many 
of the lower animals. Found by the author in the blood 
and various organs of yellow-fever cadavers in Havana 
(1888 and 1889). 

Numerous varieties have been cultivated by different 
bacteriologists, which vary in pathogenic power and to 
some extent in their growth in various culture-media; 

(39) 



40 INFANT-FEEDING. 

but the differences described are not sufficiently charac- 
teristic or constant to justify us in considering them as 
distinct species. 

Morphology. — Differs considerably in its morphology 
as obtained from different sources and in various culture- 
media. The typical form is that of short rods with 
rounded ends, from two to three microns in length and 
0.4 to 0.6 micron broad; but under certain circumstances 




Fig. 9. — Bacterium Coli Cumnrune. 

the length does not exceed the breadth — about 0.5 micron 
— and it might be mistaken for a micrococcus; again the 
prevailing form in a culture is a short oval; filaments of 
five microns or more in length are often observed in cul- 
tures, associated with short rods or oval cells. The bacilli 
are frequently united in pairs. The presence of spores 
has not been demonstrated. In unfavorable culture- 
media the bacilli, in stained preparations, may present 
unstained places, which are supposed by Escherich to be 
due to degenerative changes in the protoplasm. Under 



BACTERIUM COLI COMMUNE. 41 

certain circumstances some of the rods in a pure culture 
have been observed by Esclierich to present spherical, 
unstained portions at one or botli extremities, which 
closely resemble spores, but which lie was not able to 
stain by the methods usually employed for staining spores, 
and which he is inclined to regard as "involution forms." 

The bacillus stains readily with the aniline colors 
usually employed by bacteriologists, but quickly parts 
with its color when treated with iodine solution — Gram's 
method — or with diluted alcohol. 

Biological Characters. — An aerobic and facultative 
anaerobic, non-liquefying bacillus. Sometimes exhibits 
independent movements, which are not very active. One 
rod of a pair, in a hanging-drop culture, may advance 
slowly with a to-and-fro movement, while the other fol- 
lows as if attached to it by an invisible band (Esclierich). 
The writer's personal observations lead him to believe 
that, as a rule, this bacillus does not exhibit independent 
movements. Does not form spores. Grows in various 
culture-media at the room-temperature — more rapidly in 
the incubating oven. Grows in a decidedly acid medium. 

In gelatin plates colonies are developed in from 
twenty-four to forty-eight hours, which vary considerably 
in their appearance according to their age, and in differ- 
ent cultures in the same medium. The deep colonies are 
usually spherical and at first are transparent, homogene- 
ous, and of a pale-straw or amber color by transmitted 
light; later they frequently have a dark-brown, opaque 
central portion surrounded by a more transparent periph- 
eral zone; or they may be coarsely granular and opaque; 
sometimes they have a long-oval or "whetstone" form. 
The superficial colonies differ still more in appearance; 
very young colonies by transmitted light often resemble 
little drops of water or fragments of broken glass; when 
they have sufficient space for their development they 
quickly increase in size, and may attain a diameter of 
three to four centimetres; the central portion is thickest, 



42 INFANT-FEEDING. 

and is often marked by a spherical nucleus of a dark- 
brown color when the colony has started below the surface 
of the gelatin; the margins are thin and transparent, the 
thickness gradually increasing toward the centre, as does 
also the color, which by transmitted light varies from 
light-straw color or amber to a dark brown. The outlines 
of superficial colonies are more or less irregular, and the 
surface may be marked by ridges, fissures, or concentric 
rings, or it may be granular. The writer has observed 
colonies resembling a rosette, or a daisy with expanded 
petals. Escherich speaks of colonies which present star- 
shaped figures surrounded by concentric rings. 

In gelatin stick cultures the growth upon the surface 
is rather dry, and may be quite thin, extending over the 
entire surface of the gelatin, or it may be thicker, with 
irregular, leaf-like outlines and with superficial incrusta- 
tions or concentric annular markings. An abundant de- 
velopment occurs all along the line of puncture, which, 
in the deeper portion of the gelatin, is made up of more 
or less closely crowded colonies; these are wmite by re- 
flected light, and of an amber or light-brown color by 
transmitted light; later they may become granular and 
opaque. Frequently a diffused cloudy appearance is ob- 
served near the surface of the gelatin, and under certain 
circumstances branching, moss-like tufts develop at in- 
tervals along the line of growth. One or more gas-bubbles 
may often be seen in recent stick cultures in gelatin. 

Upon nutrient agar and blood-serum, in the incu- 
bating oven, an abundant, soft, shining layer of a brown- 
ish-yellow color is developed. The growth upon potato 
differs considerably, according to the age of the potato. 
According to Escherich, upon old potatoes there may be 
no growth, or it may be scanty and of a white color. In 
milk at 37° C, an acid reaction and coagulation of the 
casein are produced at the end of eight or ten days. In 
the absence of oxygen this bacillus is able to grow in solu- 
tions containing grape-sugar (Escherich). In bouillon it 



BACTERIUM COLT COMMUNE. 43 

grows rapidly, producing a milky opacity of the culture- 
liquid. The thermal death-point of Emmerich's bacillus, 
and of the colon bacillus from faeces, was found by Weis- 
ser to be G0° C, the time of exposure being ten minutes. 
The author has obtained corresponding results. Weisser 
found that when the bacilli from a bouillon culture were 
dried upon thin glass covers they failed to grow after 
twenty-four hours. These results give confirmation to 
the view that the bacillus under consideration does not 
form spores. 

Pathogenesis. — Comparatively small amounts of a 
pure culture of the colon bacillus injected into the cir- 
culation of a guinea-pig usually cause the death of the 
animal in from one to three days, and the bacillus is found 
in considerable numbers in its blood. But, when injected 
subcutaneously or into the peritoneal cavity of rabbits or 
guinea-pigs, a fatal termination depends largely on the 
quantity injected; and, although the bacillus may be ob- 
tained in cultures from the blood and the parenchyma of 
the various organs, it is not present in large numbers, and 
death appears to be due to toxaemia rather than to septi- 
caemia. Mice are not susceptible to infection by subcu- 
taneous injection. Small quantities injected underneath 
the skin of guinea-pigs usually produce a local abscess 
only; larger amounts — two to five cubic centimetres — 
frequently produce a fatal result, with symptoms and path- 
ological appearances corresponding with those resulting 
from intravenous injection. These are fever, developed 
soon after the injection, diarrhoea, and symptoms of col- 
lapse appearing shortly before death. At the autopsy the 
liver and spleen appear normal, or nearly so ; the kidneys 
are congested and may present scattered punctiform ec- 
chymoses (AVeisser). According to Escherich, the spleen 
is often somewhat enlarged. The small intestine is hyper- 
aemic, especially in its upper portion, and the peritoneal 
layer presents a rosy color; the mucous membrane gives 
evidence of more or less intense catarrhal inflammation, 



44 INFANT-] Kl. 1)1 NO. 

and contains mucus, often slightly mixed with blood. In 
rabbits death occurs at a somewhat later date, and diar- 
rhoea is a common symptom. In dogs the subcutaneous 
injection of a considerable quantity of a pure culture may 
give rise to an extensive local abscess. 

Varieties. — Looker, in his extended studies relating 
to the bacteria present in the faeces of infants Buffering 
from summer diarrhoea, has isolated seven varieties "which 
closely resemble bacterium coli commune in morphology 
and growth in agar, neutral gelatin, and potato, but by 
means of other tests a distinction can be made between 
them." These are described as follow-: — 

BACILLUS "d" OF BOOKER. 

"Found in two cases of cholera infantum and the 
predominating form in one serious case of catarrhal en- 
teritis. 

"Morphology. — Resembles bacterium coli commune. 

"Growth in Colonies. — Gelatin: Colonies grow lux- 
uriantly in gelatin, and thrive in acid and sugar gelatin 
equally as veil as in neutral gelatin. In the latter the 
colonies closely resemble, but are not identical with, the 
bacterium coli commune. In acid Gelatin thev differ very 
much from bacterium coli commune. * The colonies spread 
extensively, and are bluish white, with concentric rings. 
Slightly magnified, they have a large, uniform, yellow 
central zone surrounded by a border composed of per- 
pendicular threads placed thickly together. Sometimes 
a series of these rings appear, with intervening yellow 
rings. 

"Agar: The colonies are round, spread out, and blue 
or bluish wdrite. Slightly magnified, they have a pale- 
yellow color. 

"Stab Cultures. — Gelatin: In sugar gelatin the sur- 
face growth has a nearly colorless centre surrounded by a 
thick border, with an outer edge of fine, hair-like fringe; 
the growth along the line of inoculation is fine and deli- 



BACILLI s '"J." or BOOKER. 45 

cate. In neutral gelatin the growth is not so luxuriant 
as on BUgar gelatin; on the surface it is thick and white, 
with a delicate .-talk in the depth. 

"Agar: Thick white surface growth, with a well- 
developed stalk in the depth. 

''Potato: Luxuriant yellow, glistening, moist, and 
slightly raised surface, with well-defined borders. 

"Action on Milk. — Coagulated into a gelatinous coag- 
ulum in twenty-four hours at 38° C, and into a solid clot 
in two days. 

"Milk-Litmus Reaction. — Milk colored blue with lit- 
mus is changed to light pink in twenty-four hours at 38° 
C. The pink color gradually fades, and by the second or 
third day is white or cream color, with a thin layer of 
pink on top. The pink color extends in a few days about 
one-half clown the clot. 

"Temperature. — Grows best about 38° C. 

"Spores have not been observed. 

"Gas-production. — Gas-bubbles are produced in milk; 
not observed on potato." 



BACILLUS "e" OF BOOKEE. 



"Found as the predominating form in two cases of 
dysentery, one of w T hich was fatal and the other a mild 
case. 

"Morphology. — Resembles bacterium coli commune. 

"Growth in Colonies. — Gelatin: The colony growth 
varies considerably with slight difference in the gelatin. 
In 10-per-cent. neutral gelatin the colonies resemble those 
of bacterium coli commune. On the second or third day, 
when the colonies have just broken through the surface 
and are spread out, it is impossible to distinguish one 
variety from the other, but as the colonies grow older 
a difference can generally be recognized. In sugar and 
acid gelatin the colonies have a clear centre with white 
border. Slightly magnified, a uniform brown centre sur- 
rounded by a brown zone composed of fine, needle-like 



46 INFANT-FEEDING. 

rays perpendicular to the border. After cultivating for 
a few generations on acid and sugar gelatin the colonics 
cease to develop, and either grow in very small colonics 
or do not grow at all. The activity is regained if culti- 
vated on neutral gelatin. 

"Agar: Colonies are large, round, and have a mother- 
of-pearl appearance. Slightly magnified, a uniform yel- 
low color. 

"Stab Cultures. — Agar: Luxuriant, nearly colorless 
surface growth, with well-developed stalk along the line 
of inoculation in the depth. 

"Potato: Golden-yellow, glistening, slightly raised 
surface, with well-defined borders. 

"Action on Milk. — Milk becomes gelatinous in twenty- 
four hours at 38° C, and in a few days a solid coagulum 
is formed. Milk colored blue with litmus is reduced to 
white or cream color in twenty-four to forty-eight hours 
at 38° C, with a thin layer of pink at the top of the 
culture. The pink color gradually extends lower in the 
coagulum. 

"Temperature. — Thrives best at about 38° C. 

"Spores have not been observed. 

"Gas-production. — Occurs in milk, but not seen in 
potato cultures. 

"Relation to Gelatin. — Does not liquefy gelatin. 

"He semblance. — Resembles bacterium coli commune 
and bacillus c d/ differing from the former in the charac- 
ter of the colony growth on acid and sugar gelatin and in 
ceasing to develop in these media after several genera- 
tions. It differs from bacillus '<¥ in this latter respect.'' 

BACILLUS "f" OF BOOKER. 

"Found in one case of cholera infantum and one case 
of catarrhal enteritis. 

"Morphology. — Resembles bacterium coli commune. 

"Growth in Colonies. — Gelatin: It is difficult to dis- 
tinguish the colony growth from the bacterium coli com- 



BACILLUS "F" OF BOOKER. 47 

nrane. There is often a difference in the colonies planted 
at the Bame time and kept under similar conditions, but 

it is not very marked nor always the same kind of differ- 
ence. The tendency to concentric rings is greater in this 
variety. The colonies develop somewhat better on neutral 

and sugar gelatin than on acid gelatin. 

"Agar: The colonies are large, round, and bluish 
white. Slightly magnified, a light-yellow color. 

"Slab Cultures. — Gelatin: The culture is spread over 
the surface and has a mist-like appearance; in the depth 
along the line of inoculation is a delicate stalk. 

"Agar: Thick, luxuriant, white surface growth, with 
a well-developed stalk along the line of inoculation in the 
depth. 

"Potato: Bright-yellow, glistening, moist surface, 
with well-defined borders, and but slightly raised above 
the surrounding potato. 

"Action on 21 ilk and Litmus Reaction. — Milk is co- 
agulated into a solid clot in twenty-four hours at 38° C, 
and in forty-eight hours is reduced to white or cream 
color with a thin pink layer on top. 

"Gas-production. — Gas-bubbles arise in milk cultures, 
but they have not been observed on potato cultures. 

"Temperature. — Grows better at 38° C. 

"Spores have not been observed. 

"Fetation to Gelatin. — Does not liquefy gelatin. 

"Resemblance. — It closely resembles bacterium coli 
commune and Brieger's bacillus in the character of its 
growth upon different media, but is readily distinguished 
from both, as is also Brieger's bacillus from the bacterium 
coli commune, by the following differential test recently 
made known by Dr. Mail: Yellow elastic tissue from the 
ligamentum nuchae of an ox is cut into fine bits and is 
placed in test-tubes containing water with 10-per-cent. 
bouillon and 1-per-cent. sugar, and sterilized from one 
and one-half to two hours at a time for three consecutive 
days. Into this is inoculated two species of bacteria, one 



-18 INFANT-FEEDING. 

of which is the bacterium under observation, the other a 
bacillus found in garden earth. The latter bacillus is 
anaerobic; grows in hydrogen, nitrogen, and ordinary 
illuminating gas; in the bottom of bouillon; in the depth, 
but not on the surface, of agar stab cultures, and not at 
all in gelatin stab cultures. It has a spore in one end, 
making a knob bacillus. Different species of bacteria — 
streptococcus Indicus, tetragcnus, cholera, swine plague, 
bacterium lactis aerogenes, bacterium coli commune, 
Brieger's bacillus, and a number of varieties of bacteria 
which I have isolated from the fseces — were inoculated 
with head bacillus into the above-described elastic-tissue 
tubes. The tubes inoculated with Brieger's bacillus de- 
velop a beautiful purple tint, which started as a narrow 
ring at the top of the culture, gradually extending down- 
ward and deepening in color until the wdiole tube has a 
dark-purple color. This color-reaction began in five to 
fourteen days, and w r as constantly present in a large num- 
ber of tests. Tubes inoculated with bacillus 'f gave a 
much fainter purple color, which w r as longer in appearing 
and never became so dark as with Brieger's bacillus. 

"Tubes inoculated with the other species of bacteria 
above mentioned gave no color-change and remained simi- 
lar to control. Bacillus 'f also shows a slight difference 
from bacterium coli commune in coagulating milk and 
reducing litmus more rapidly, and appears to produce 
more active fermentation in milk. Like Brieger's bacillus, 
the gelatin colonies more frequently show a concentric 
arrangement than those of the bacterium coli commune." 

BACILLUS "g" OF BOOKER. 

"Found in one case of serious gastro-enteric catarrh. 
It was not in large quantity. 

"Morphology and Biological Characters. — In mor- 
phology, character of growth on agar, gelatin, and potato, 
it resembles bacterium coli commune. 



BACILL] "ii" AM) te K" OF BOOKER. 49 

"Action o)i Milk and Litmus Reaction. — Milk is not 
coagulated, and milk colored blue with litmus is changed 
to pink in a few days, and holds this color. These charac- 
teristics distinguish it from the bacterium coli commune. 

"Gas-production. — Not observed in milk or potato 
cultures. 

"Relation to Gelatin. — Does not liquefy gelatin." 

BACILLUS "h" OF BOOKER. 

"Found in one case of mild dysentery, not in large 
quantity. 

"Morphology. — Resembles bacterium coli commune. 

"Growth in Colonies. — Gelatin: In plain neutral 
gelatin the colonies resemble those of bacterium coli com- 
mune. In sugar gelatin the colonies are white and spread 
extensively. Slightly magnified, they have a round, dark 
centre surrounded by a yellow, loose zone with an outer 
white rim; later the whole colony has a uniform yellow 
color and is not compact. 

"Agar: Colonies are white, round, and large. Slightly 
magnified, they are brownish yellow. 

"Stab Cidtures. — Nothing characteristic in gelatin 
and agar. 

"Potato culture is yellow, dry, and slightly raised, 
with w T ell-defined borders. 

"Action on Milk and Litmus Reaction. — Milk is co- 
agulated into a solid clot in two days at 38° C. Milk 
colored blue with litmus is changed to pink in twenty-four 
hours. 

"Gas-production. — Occurs in milk; not observed on 
potato. 

"Relation to Gelatin. — Does not liquefy gelatin." 



BACILLUS "k" OF BOOKER. 



"Found in two cases of cholera infantum and one of 
catarrhal enteritis. 



50 INFANT-FEED! 

"Morphology. — Reseml rium coli commune. 

"''rou'tli in Colonies. — Gelatin: In neutral gelatin 
the colonies cannot be distinguished fn 
terium coli commune. In acid gelatin the colonies do not 
spread so extensively as those of bacterium coli commune, 
and they have a d I concentric arrangement; a wide 

white centre surrounded by a narrow, transparent blue 
ring; and outside of this a white border. Slightly mag- 
nified, the colonies have an irregular, yellowish-brown 
centre, mottled over with dark spots and surrounde<; 
a light-yellow ring bordered by a brownish-yellow wreath. 

'"Agar: Colonies are large, round, and bluish white. 
Sliohtlv magnified, a light-brownish-yellow color. 

"■^ : ab Cultures. — Gelatin: In sugar gelatin the sur- 
face growth is extensive; nearly colorless; and h; - 
rough, misty appearance. In the depth is a delicate 
growth. In plain neutral gelatin the surface growth is 
bluish white, thick, and not so extensively spread; the 
growth in the depth is also thicker. 

"Potato culture is moist, dirty-cream color, has raised 
surface and defined border. 

"Action on Mill:. — Milk becomes gelatinous in twenty- 
four hours at 35 ~ C, and a solid clot in two days. Milk 
colored blue with litmus is changed to pink in twenty- 
four hours, and reduced to white, with a pink layer on 
top, in two days." 

BACILLUS 'V OF BOOKEE. 

"Found in large quantity, but not the predominating 
form, in one case of chronic gastro-enteric catarrh (ex- 
tremely emaciated). 

"Morphology. — Resembles bacterium coli commune. 

"Growth in Colonies. — Gelatin: In neutral gelatin 
the colonies are spread out and have a frosty, ground- 
glass, appearance. The centre is blue and border white, 
but both have the ground-glass appearance. Slightly m _- 
nified, the central part is light yellow and the border 



BACTERIUM l \« n 8 \i:i:<»..;.\ ES. 51 

brown, with a rough, furrowed surface. Ill acid gelatin 
the white border is wider and the surface is rougher. 

"Agar: Colonies are round, blue, or bluish white, and 
spread out. Under the microscope they have a light-yel- 
low color. 

"Stab Cultures. — Gelatin: Has a rough, nearly color- 
less surface growth, and a thick stalk in the depth along 
the line of inoculation. • 

"Agar: Thick white surface growth, with well-devel- 
oped stalk in the depth. 

"Action on Milk and Litmus Reaction. — Milk re- 
mains liquid and milk colored blue with litmus is changed 
to pink. 

u Gas-production. — Xot observed in milk or potato 
cultures. 

"Relation to Gelatin. — Does not liquefy gelatin. 

"Spores have not been noticed." 16 

BACTERIUM LACTIS AEEOGEXES. 

Synonym. — Bacillus lactis aercgenes (Escherich). 

Obtained by Escherich (1886) from the contents of 
the small intestine of children and animals fed on milk; 
in smaller numbers from the faeces of milk-fed children, 
and in one instance from uncooked cows' milk. 

Morphology. — Short rods with rounded ends, from 
1 to 2 microns in length and from 0.1 to 0.5 micron 
broad; short-oval and spherical forms are also frequently 
observed, and under certain circumstances longer rods — 
3 microns — may be developed; usually united in pairs, 
and occasionally in chains containing several elements. 
In some of the larger cells Escherich has observed un- 
stained spaces, but was not able to obtain any evidence 
that these represent spon s. 

This bacillus stains readily with the ordinary aniline 
colors, but does not retain its color when treated by 
Oram's method. 



Sternberg's "Manual of Bacteriology," 1892. 



INFANT-FEEDING. 

JHological Characters. — An aerobic (facultative an- 
aerobic), non-liquefying, non-motile bacillus. Does not 
form spores. Grows in various culture-media at the room- 
temperature — more rapidly in the incubating oven. Upon 
gelatin plates, at the end of twenty-fours hours, small, 
white colonies are developed. Upon the surface these 
form hemispherical, soft, shining masses which, examined 
under the microscope, are found to be homogeneous and 
opaque, with a whitish lustre by reflected light. The deep 
colonies are spherical and opaque, and attain a consider- 
able size. In gelatin stick cultures the growth resembles 
that of Friedlander's bacillus; i.e., an abundant growth 
along the line of puncture and a rounded mass upon the 
surface, forming a "nail-shaped" growth. In old cult- 
ures the upper part of the gelatin is sometimes clouded, 
and numerous gas-bubbles may form in the gelatin. Upon 
the surface of nutrient agar an abundant, soft, white layer 
is developed. Upon old potatoes, in the incubating oven, 
at the end of twenty-four hours a yellowish-white layer, 
several millimetres thick, is developed, which is of paste- 
like consistence and contains about the periphery a con- 
siderable number of small gas-bubbles; this layer in- 
creases in dimensions, has an irregular outline, and larger 
and more numerous gas-bubbles are developed about the 
periphery, some the size of a pea; later the whole surface 
of the potato is covered with a creamy, semifluid mass 
filled with gas-bubbles. On young potatoes the develop- 
ment is different; a rather luxuriant, thick, white or pale- 
yellow layer is formed, which is tolerably dry and has 
irregular margins; the surface is smooth and shining, and 
a few minute gas-bubbles only are formed after several 
days. 

Pathogenesis. — Injections of a considerable quantity 
of a pure culture into the circulation of rabbits and of 
guinea-pigs give rise to a fatal result within forty-eight 
hours. 

In his first publication relating to "the bacteria found 



n.U'TKULUM LACTUS AEROGENES. 



53 



in the dejecta of infants afflicted with summer diarrhoea," 
Booker has described a bacillus which he designates by 
the letter "b," which closely resembles bacillus lactis 
aerogenes and is probably identical with it. He says: — 
"Summary of Bacillus 'b.' — Found nearly constantly 
in cholera infantum and catarrhal enteritis, and generally 
the predominating form. It appeared in larger quantities 
in the more serious cases. It was not found in the dysen- 




V't 



Fig. 10. — Bacterium Lactis Aerogenes. 



teric or healthy faeces. It resembles the description of the 
bacillus lactis aerogenes, but the resemblance does not 
appear sufficient to constitute an identity, and, in the ab- 
sence of a culture of the latter for comparison, it is con- 
sidered a distinct variety for the following reasons : Bacil- 
lus 'b' is uniformly larger, its ends are not so sharply 
rounded, and in all culture-media long, thick filaments 
are seen, and many of the bacilli have the protoplasm 
gathered in the centre, leaving the poles clear. There is 



•• 1 [NFANT-FEEDING. 

some difference in their colony growth on gelatin, and in 
gelatin stick cultures bacillus V docs not show the nail- 
form growth with marked end-swelling in the depth. In 
potato cultures the bacillus lactis aerogenes Bhows a differ- 
ence between old and new potatoes, while bacillus 'b' does 
not show any difference. 

"Bacillus 'h' possesses decided pathogenic properties, 
which were shown both by hypodermic injections and 
feeding with milk cultures." 



CHAPTER IX. 

Colostrum. 

Colostrum is found in the breast of a woman several 
hours after birth. It resembles milk, but is a much 
thinner fluid. It is always the forerunner of a healthy 
normal secretion of breast-milk, which usually appears 
on the third day after the birth of the infant. 

Colostrum is the earliest milk, very thin and watery 



^5Q^o% 




Colostrum- 
corpuscles 



Fig. 11. — From a Drop of Milk on the Third Day after Deliv- 
ery, kindly Furnished by Dr. H. L. Collyer, showing Co- 
lostrum-corpuscles. The specimen drawn by Dr. Julian W. 
Brandeis. (Zeiss Ocular 4, dd Lens.) 



in color, very rich in salts, with decided purgative prop- 
erties, saving all useless castor-oil, honey, and butter and 
all sugar-water, with which mothers and nurses delight 
to experiment. 

According to Baginsky, colostrum contains large 
quantities of serum-albumin, is also very rich in fat and 
colostrum-corpuscles, and contains a large quantity of 

(55) ' 



oG INFANT-FEEDING. 

Baits. The last two ingredients are supposed to be the 
cause of the laxative action of the colostrum. 

Immunity by Breast-milk. 

It is a well-known fact, and one that has been brought 
out most prominently by Brieger and Ehrlich and Bagin- 
sky, that immunity can be conferred on a child by nurs- 
ing the milk of its mother. This question has also been 
studied with reference to conferring immunity in infec- 
tious diseases, and H. Neumann has found that immu- 
nity can be conveyed to an infant by the agency of breast- 
milk. 

The Two Mammary Glands. 

The two mammary glands of the same woman may 
yield somewhat different milk, as shown by Sourdat and 
later by Brunner. Also the different portions of milk 
from the same milking may have different compositions. 
The first portions are always poorer in fat (Parmentier, 
Peligot, and others). 

According to 1'Heritier Yernois and Becquerel, the 
milk of blondes contains less casein than that of bru- 
nettes: a difference which Tolmatscheff could not sub- 
stantiate. Women of weak constitutions yield a milk 
richer in solids, especially in casein, than women with 
strong constitutions. 

According to Yernois and Becquerel, the age of the 
woman has an effect on the composition of the milk, so 
that we find a greater quantity of proteids and fat in 
women 15 to 20 years old and a smaller quantity of sugar. 
The smallest quantity of proteids and the greatest quan- 
tity of sugar are found at 20 or from 25 to 30 years of 
age. The milk with the first-born is richer in water — 
with a proportionate diminution of the quantity of casein, 
sugar, and fat — than after several deliveries. The influ- 
ence of menstruation seems to slightly diminish the milk- 
sugar and to considerably increase the fat and casein. 



WITOB a MILK, in 

Witch's Milk. 

Witch's milk is the secretion of the mammary glands 
of newborn children of both sexes immediately after birth. 
This secretion has, from a qualitative standpoint, the 
same constitution as milk, but may show important dif- 
ferences and variations from a quantitative point of view. 
Schlossberger and HaufT, Gubler and Quevennc, and von 
Gesner have made analyses of this milk, and give the 
following results: 10.5-28 p. m. proteids, 8.2-14.6 p. m. 
fat, and 9-60 p. m. sugar. 

The newborn human infant almost constantly se- 
cretes a fluid in the mammae, and adult males have not 
only secreted milk, but that in abundance enough to 
suckle. Females, also, both human and animal, occasion- 
ally secrete milk without having been previously preg- 
nant. With regard to the milk secreted by infants, there 
is some doubt about its real nature. Kollicker does not 
view it as a true milk, but considers its appearance con- 
nected with the formation of the mammary glands. 

Sinety, on the other hand, upon anatomical grounds 
considers it a true lacteal secretion. It probably is a sort 
of imperfect milk, loaded with leucocytes, and this is 
the more likely as Vollard 17 notices that it frequently 
ends in abscess. 

Schlossberger gives an imperfect quantitative anal- 
ysis of a sample of milk obtained by squeezing the breasts 
of a newborn infant, a male. In the course of a few days 
about a drachm was obtained. The following was the 
result of the analysis: — 

Water 9G.75 

Fat 0.82 

Ash 0.05 

Casein, sugar, and extractives 2.83 

Sugar-reaction strong. 



I rait r- des Maladies des Enfants nouveau-iu's,"' third edition, 
1837, p. 717. 



]\i \\t-it.i:i)I\'<;. 

The most complete analysis we possess of such milk 
ia by von ( lesner: — 

Milk-fat 1.456 

Casein 0.557 

Albumin 0.490 

Milk-sugar 0.956 

Ash 0.82G 

Water 95.705 

Total solids 4.295 



Joly and Filhol have recorded the case of an old lady, 
75 years of age, who suckled successfully her grandchild. 
Similar instances have been recorded in dogs, and we 
fortunately possess one or two analyses which show that 
the fluid is certainly milk. Thus, Filhol and Joly give 
the following analvsis of the milk derived from a bitch 
which had no connection with a male: — 

Specific gravity 1.069 

Total solids 29.00 

Fat 2.20 

Sugar 0.32 

Albumin 23.20 

The ash, on analysis, gave the following percentage : — 

Chloride of sodium 65.10 

Chloride of potassium : 3.S8 

Calcic phosphate 27.75 

Sodic phosphate 1.40 

Sodic carbonate 1.87 

Traces of magnesia and other phosphates. 



Men Suckling Ciiildeex. 

Men before now have suckled children. Humboldt 
relates the case of Francisco Lozano, whom he saw, and 
whose ease he carefully investigated; and it appeals 



Mi:\ SUCKLING CHILDREN. 59 

established that this man did secrete from his breasts a 
nutrient fluid, on which his infant son lived for many 
months; it is said, indeed, a whole year. The curious 
in such matters may consult the references given farther 
on. 18 



18 1. "Untersuchung der sogenannte Hexenmilch." J. Schloss- 
berger, Annalen der Chemie und Pharmacie, B. 87, 1852. 2. Robert 
Bisliop of Cork: letter concerning a man who gave suck to a child. 
Phil. Trans., 1741, No. 461, page 813, etc. 



CIIAPTEK X. 



Breast-milk. 



According to Pfeiffer, human milk contains, several 
days after the birth of the baby, a large quantity of albu- 
min, salt, and a small quantity of fat. He also found 




Fig. 12. — This Illustration was Drawn by Dr. J. W. Brandeis 
from a Drop of Breast-milk Taken from a Wet-nurse Em- 
ployed in the Author's Family. It Represents a Beautiful 
Emulsion of Evenly-Divided Fat-globules. Note the Reg- 
ularity of their Size. 



that the longer the period of nursing {he smaller the 
quantity of albumin, which, in the eleventh month, sinks 
(60) 



BREAST-MILK. 



61 




Fig. 13. — Shewing a Drop of Milk under the Microscope. Note 
the poor character of this emulsion, the uneven fat-globules, 
and their irregular size and distribution. The infant nursed 
■with the above milk was rachitic and colicky. Although 
15 months old, no tooth had appeared. The mother of the 
infant states that she menstruated every twenty-one or 
twenty-two days since her infant was born — during this 
present nursing period. 




Fig. 14. — This Drop of Breast-milk is from a very Anaemic 
Woman. The child was extremely emaciated; had greenish 
stools, and colic, and was always crying. Xote the uneven 
character of above emulsion, when compared with Fig. 12. 
The infant was poorly nourished; had rickets and marked 
cranio-tabes. Mixed feeding was resorted to, with decided 
improvement. 



G2 INFANT-FEEDING. 

quite low. There is also a decrease in the quantity of 
salts, whereas the amount of sugar steadily increases. 
The fat varies constantly. According to Johannessen, 
the quantity of albnmin in the first six months is 1.192 
per cent.; in the next six months 0.989 per cent.; and 
at the end of the year 0.907 per cent. 

Breast-milk varies according to the length of time 
that it remains in the breast, and also the length of the 
nursing period; so it has been shown that the first milk 
taken at the beginning of the nursing act is the poorest 
in nutrient value, whereas the last milk is richest in fat. 
The longer the milk remains in the glands of the breast, 
the more will the solid substances of the same be ab- 
sorbed, so that only a watery solution remains. If suck- 
ing is commenced, this stimulation soon changes the char- 
acter of this watery milk, so that normal milk will soon 
be secreted. Forster studied the chemical constitution 
of the first, middle, and the last portions of milk from 
a nursing woman, with the following result. 

In one hundred parts he found: — 

First Portion of the Nursing Act. 

Water 90.24 

Nitrogenous substances 1.13 

Fat 1.70 

Sugar 5.56 

Ash 0.46 

The quantity examined was 33.1 grammes. 



Second Portion (during the Nursing). 

Water 89.68 

Nitrogenous substances 0.94 

Fat 2.77 

Sugar 5.70 

Ash 0.32 

The quantity examined was 33.1 grammes. 



BREAST-MILK. G3 

Third Portion (at the End of the Nursing Act). 

Water 87.50 

Nitrogenous substances 0.71 

Fat : 4.51 

Sugar 5.10 

Ash 0.28 

The quantity examined was 37.3 grammes. 

From a study of the foregoing tables we find a decrease 
of nitrogenous substances during the course of the nurs- 
ing, a steady increase in the amount of fat, and an un- 
varying percentage of sugar. Thus, it is apparent that, 
in order to submit a specimen of breast-milk to a chemical 
examination, it is necessary to stimulate the secretory 
functions of the mammary glands by putting the child 
to the breast at least two minutes; thus an even milk can 
be procured. If this rule is overlooked, then we shall find 
proportions in the chemical components of milk which 
might otherwise be entirely different. The most recent 
chemical analysis of breast-milk shows that in a hundred 
parts there are: — 

Solids 11.5 

Liquids 88.5 

Of the solid constituents there is : — 

Casein 1.2 to 1.03 

Albumin 0.5 

Tat 0.8 to 4.07 

Milk-sugar 6.0 to 7.03 

Ash 0.2 to 0.21 

The above is the chemical examination of a good 
average breast-milk. I again call attention to the fact, 
however, that not only does the milk vary in different 
women, but it also varies in the same woman during one 
single nursing act. 



64 INFANT-EEEDING. 

The albuminoids of milk consist of real casein, lac- 
talbuniin, globulin, and opalisin. This latter body has 
only recently been discovered by A. Wroblewski, and 
more recently by Schlossmann. 

Phosphorus exists in milk as nuclein-phosphorus. 
Wittmaack has demonstrated the fact that the phosphorus 
in woman's milk exists as an organic nitrogen compound 
in the casein. 

According to the examination of Stolasa, lecithin con- 
tains a larger quantity of phosphorus in woman's milk 
than in cows' milk. 

The specific gravity of breast-milk varies from 1.026 
to 1.036. 



SPECIMEN OF BEEAST-MILK EOR CHEMICAL 
EXAMINATION. 

After the third, possibly the fourth, day the average 
healthy woman secretes milk that gradually becomes nor- 
mal in quality and quantity, depending on her general 
condition. It is usual for an infant to lose some weight 
during its first week of life, owing to various physiological 
changes, added to which is, no doubt, the deficiency in 
the quality and quantity of its food. It is a safe plan, 
and one that I have always urged, if at all possible, to 
send a specimen of breast-milk to a chemist and submit 
the same to a chemical analysis. In some women a spec- 
imen can be examined when the baby is one week old; 
in others it is better to wait until the end of two weeks. 
We then would have a proper working basis, and know 
just how much fat, carbohydrate (sugar), and albuminoids 
■ — including proteids — we are feeding. Noting the weight 
of the child, its sleep, its digestion, color and frequency 
of its stools, we can easily see in one week how much the 
infant has gained in weight, and its general condition. 
To take a specimen, it is advisable to have all utensils 
absolutely clean; hence the following plan would be sug- 



BREAST-MILK. 



65 



gested: Boil an ordinary one- or two- ounce bottle in 
water, to which a pinch of baking soda has been added, 
for about one-half hour. Then place the bottle in plain 
water and boil again for a half-hour. Then turn the 
bottle upside down, and allow it to drain and dry. In 
this manner we can completely sterilize the inside of the 
bottle and avoid contamination. 

Withdraw a sample of breast-milk by means of a 
breast-pump. One which has served the author very well 
is known as the Florence breast-pump, and has a glass 
mouth-piece. (See illustration, Fig. 17.) Another form 
is an English breast-pump, having a rubber bulb. Com- 
pressing this bulb, we can suck about an ounce or more 
in from five to ten minutes. This milk is to be poured 
into the bottle, and well corked, and set in a refrigerator, 
but not on the ice. Milk will keep for many hours in 
this way. My plan has been to inform the chemist the 



Human Milk. 



Normal Milks. 

Average 

Average 

Average 

Average 

14 analyses from 
same woman . 

Wean of 6, aged 
23-33 years . . 

Average 

From woman aged 
18 

From woman aged 
33 . . . 

4 days after deliv- 
ery . 

9 days after deliv- 
ery 

12 days after de- 
livery . . 

Average of 84 
samples .... 

Average of 10 7 
samples .... 



Fat. 


Pro- 

TEIDS. 


2.90 
3.68 
2.67 
3.52 


3.07 
1.70 
3.92 
2.01 


2.53 


3.42 


3.82 
3.55 


2.04 
1.52 


3.20 


2.39 


2.99 


2.51 


4.30 


3.53 


3.53 


3.69 


3.34 


2.91 


4.13 


2.00 


3.78 


2.09 



Sugar 


ASH. 


5.87 


0.16 


7.11 


0.20 


4.37 


0.14 


5.91 


• • • 


4.82 


0.23 


5.93 


0.42 


6.50 


0.45 


6.83 


0.29 


6.51 


0.30 


4.11 


0.21 


4.30 


0.17 


3.15 


0.19 


6.94 


0.20 


6.21 


0.31 



Authority. 



A. W. Blythe. 
Marchand. 
Vernois& Becquerel. 
Hammarsten. 

Simon. 

H. Gerber. 
Chevalier & Henry. 

J. Bell. 

J. Bell. 

Clemm. 

Clemm. 

Clemm. 

Leeds. 

Konisr. 



66 INFANT-FEEDING. 

day previous to submitting the sample, so that it can be 
withdrawn from the breast early in the morning — at 
about 8 a.m. — and sent to the laboratory at once. The 
result of the analysis can be received on the evening of 
the same day or on the following day in all instances. A 
point worth noting is that the very first milk — known as 
the foremilk — should not be used, but the infant should 
be allowed to suck at the breast for about two minutes 
before pumping the sample. After this the breast-pump 
should be applied for five minutes to procure the so-called 
middle milk for examination; then the infant can again 
be put to the breast to finish the so-called end of nursing 
or to suck the strippings. 



CHAPTEK XI. 

Breast-feeding. 

During the first month feed every two hours during 
the day, never oftener. During the second month, every 
two and a half to three hours. The child may be taken 
from its sleep during the day to be nursed. 

Never disturb a child from its sleep at night to be 
nursed; so that the rule should be to leave the baby rest as 
long as it appears satisfied. This rule applies to healthy 
children only. In sickness special feeding rules are re- 
quired. If the child thrives, gains in weight, then it is ad- 
visable in the interest of the mother and child to have an 
interval of from seven to eight hours at night ; thus Bou- 
chut advises feeding between 10 and 11 at night and com- 
mencing the morning meal at 6 a.m. If the child is rest- 
less, then turn it from side to side ; in other words, chang- 
ing its position and giving it 1 or 2 teaspoonfuls of boiled 
water will frequently satisfy it and prolong its sleep. 

Time for Feeding. 



From 

Birth 

until 1 

Month 

Old. 



6 A.M. 

8 A.M. 

10 A.M. 

12 Noon. 

2 P.M. 

4 P.M. 

6 P.M. 

8 P.M. 
10 P.M. 

12 Mid- 
night. 



At 






1 MONTn 


2 TO 4 


4 TO 6 


UNTIL 2 


Months 


Months 


Months 


Old. 


Old. 


Old. 






6 A.M. 


6 A.M. 


6 A.M. 


9 A.M. 


9 A.M. 


9 A.M. 


11 A.M. 


12 Noon. 


12 Noon. 


1 P.M. 


3 P.M. 


3 P.M. 


3 P.M. 


6 P.M. 


6 P.M. 


5 P.M. 


9 P.M. 


9 P.M. 


7 P.M. 


12 Mid- 




9 P.M. 


night. 




11 P.M. 







6 to 9 
Months Old. 



6 A.M. 
9.30 to 10 A.M. 
1.30 to 2 p.m. 
5.30 to 6 p.m. 
9.30 to 10 p.m. 



9 Months 

until 

1 Year 

Old. 



6 A.M. 
10 A.M. 

2 P.M. 

6 P.M. 
10 P.M. 



(6 



68 INFANT-FEEDING. 

The first three or four days after birth require special 
feeding methods: — 

On the day of the birth, the exhaustion of the mother 
and presence of colostrum, besides the normal deficient 
quantity of food in the breast, demand large intervals of 
rest; thus for the first three days (unless the milk-supply 
is profuse) putting the infant to the breast once every six 
hours would be sufficient ; if, however, the supply of milk 
is ample, then we can follow the table given above and 
nurse the infant every two hours. 

SUGGESTIONS FOE BEEAST-FEEDING. 

The mother or wet-nurse should always sit upright, 
be it at night or during the day, while nursing the infant. 

Danger of Suffocation. — A great many cases are on 
record where the mother or wet-nurse has fallen asleep 
while nursing, and smothered the child. For this reason 
it is important that the infant should sleep in its own 
crib or bed, and should never sleep with its mother or 
nurse. 

Shall an Infant Receive hut One or Both Breasts for 
One Meal? — This depends on the infant's appetite. Some 
infants appear satisfied after nursing from one breast, 
and will let the nipple go and fall asleep. Light tapping 
on the cheeks of the infant will awaken it, or the with- 
drawal of the nipple from the infant's mouth will fre- 
quently arouse the child to continue its nursing. If, 
however, an infant will not renew its nursing, and still 
continue to sleep, and if the infant has nursed steadily 
for ten minutes, then the sleep should not be disturbed. 

Length of Time for Nursing. — A good plan is to note 
the time when the nursing act commences and stops. !N"o 
infant should nurse longer than 20 minutes, whereas fre- 
quently 10 minutes or 15 minutes will suffice. If an in- 
fant nurses more than 20 minutes, say 30 or 40 minutes, 
then we may be sure that the breast-milk is deficient in 



MIXED FEEDING. 69 

quantity, and a specimen should at once be submitted for 
a proper chemical examination. 

Mixed Feeding. 

When there is a deficiency in the quantity of breast- 
milk, but the quality is good, then it is advisable to feed 
the infant alternately with breast-milk and bottle-milk. 
At the same time, it is advisable to direct attention to the 
mother's general condition, and see if we cannot tone her 
up, and thus improve both quality and quantity of her 
milk. Frequently a subnormal or ansemic condition re- 
quires iron; in other cases a day's outing to the sea-shore 
or to the country, with moderate exercise, will stimulate 
and increase the flow of milk. It is well to try some 
galactagogues. Among them the author has found an 
albumin diet (meat, milk, and eggs) and a preparation 
known as nutrolactis in tablespoonful doses before meals 
to have acted very well in some cases. Grandin and 
Jarman, in their text-book on obstetrics, recommend the 
strong infusion of galega officinalis when the flow of milk 
is scant. This is to be ordered in tablespoonful doses three 
or four times a day. Every drop of breast-milk is so 
precious that no infant should be deprived of it, and wise 
is the physician who will insist on giving all the breast- 
milk when there is deficient lactation, and supplying the 
deficiency by giving a proper diluted milk- or cream- 
mixture, adated for the age and weight of the infant. 
^ Do Drugs Taken by a Nursing Woman Affect the 
'Baby During the Nursing Period? — Physiological ex- 
periments have frequently demonstrated the fact that a 
great many drugs can be given to an infant through its 
mother's milk; thus, opium and morphine and narcotics 
in general do affect the nursling when the drugs are taken 
by the mother. Baginsky calls attention to this fact in 
his text-book on "Diseases of Children" : "Alcohol, when 
taken by the mother, is transmitted through the milk, but 
not in very large quantities. The following is a list of 



70 INFANT-FEEDING. 

drugs which have been found in milk: The purgative 
principles of rhubarb, senna, and castor-oil; the metals 
antimony, arsenic, iodine, bismuth, lead, iron, mercury; 
the volatile oils, like copaiba, garlic, and turpentine; also 
salicylic acid, and the iodides and bromides." Do not 
give cocaine, chloral, atropine, or hyoscyamus. Care is 
to be used with the following: Digitalis, antipyrin, and 
ergot. An unpleasant flavor can be imparted to the 
breast-milk by the mother or wet-nurse eating onions, 
turnips, cauliflower, or cabbage. 

Microbes in the Milk of Nursing "Women. 

Ringel 19 examined the milk of 25 women, 12 of 
whom were healthy. With minute precaution to insure 
accuracy, he found the milk sterile in only 3 cases; he 
obtained the white staphylococcus in 17, the yellow in 2, 
the two together in 1 case, and in 2 instances he found 
the white staphylococcus together with the streptococcus. 
As the microbes could not be due to genital infection, 
the idea was suggested that they might come from the 
child's mouth, the white staphylococcus having been, in 
fact, found on the child's tongue. But having examined 
the milk of a woman who had not been suckling, but 
whose nipples had been disinfected, Ringel still found 
the staphylococcus. 

Sterility of Human Milk. 

Honigmann finds that human milk obtained with all 
antiseptic precautions from 73 breasts of 64 nursing 
women was only sterile, when duly cultivated, in 4 cases. 
In the remainder staphylococcus albus was present, and 
in 44 cases the staphylococcus aureus; while in 3 in- 
stances other bacteria — a bacillus and a sarcina — were 
found. The number of germs varied from 1 to upward 



19 Munch, med. Wochenschrift, No. 27 ; British Gynaecological 
Journal, xxxvi; Brooklyn Medical Journal, August, 1894. 



ADDITIONAL FOODS DURING NURSING PERIOD. 71 

of 9000 in a cubic millimetre. These observations are of 
interest in reference to the occurrence of thrush in chil- 
dren, to the origin of which they may furnish a clew, and 
also to the liability that children, while suckling, present 
to suppuration after wounds accidentally or intentionally 
inflicted. (Lancet.) 

Fat-globules. 

Woman's milk has larger fat-globules than cows' milk. 
Their number, according to Bouchut, is one to two mil- 
lions in 1 cubic centimetre. It has less inclination to turn 
acid; therefore it does not coagulate distinctly. 

Additional Foods During the [Nursing Period. 

Flour-Ball Feeding. — "When an infant nursing at the 
breast is six months old certain additions to the food can 
safely be made; thus, for example, the white of a raw 
egg can be given every second day, and on the alternate 
day several teaspoonfuls of a meat-soup (beef or chicken) 
in which barley, farina, or sago has been boiled and 
strained. This method of feeding can be kept up until 
the child is seven or even eight months old, and then a 
small piece of zwieback can be allowed every day. As 
this is hard, children like to nibble on it, for it seems to 
soothe their gums. If the bowels are in a good condition, 
then a few teaspoonfuls of a very light wheat-flour ball 
can be given every few days. Flour ball can best be made 
by following the directions given by Dr. Edwin Rosenthal 
(Paper read before the Pennsylvania State Society, May 
18, 1898, entitled ''Some Points on Infant-feeding"); he 
says: "I use the following formula, and I can claim as 
much good results therefrom as from any form of modi- 
fied home-made food. It is known as the flour-ball food, 
commercially imperial granum. It is made as follows: 
Plain wheat-flour is boiled in a bag for five hours, then 
dried, broken open, the rind rejected, and then grated into 
a powder. I take of pure milk, mixed and scalded, 1 pint; 



72 INFANT-EEEDING. 

of sterile water, 1 pint; of the boiled flour, a heaping 
tablespoonful, a bit of cinnamon-bark (sometimes to give 
some flavor with certain children), and a pinch of com- 
mon table-salt. The milk is placed on the fire and heated ; 
the flour is rubbed to a fine paste with the water, and then 
added to the milk. The cinnamon is added, and then it 
is brought to the boiling-point, taken from the fire, the 
salt added (not sufficient to taste), and the whole is then 
placed on the ice. It is then heated again when used. 
Two ounces every two hours is given to a child one month 
old. It is increased 1 / 2 ounce every month, while the 
water is reduced 1 ounce every month. The milk is added 
to keep the quantity up to the 2 pints. I have with this 
method seen some very surprising results, and feel no 
hesitancy in recommending it." 

The Addition of Hydrochloric Acid to Food. — The 
indiscriminate use of dilute hydrochloric acid is a prac- 
tice that is to be condemned. We know that hydrochloric 
acid passes through the body unchanged, and in being- 
excreted by the kidneys frequently irritates the same. A 
point to note is that HC1 is formed in the stomach from 
the chlorides in the circulation of the blood. It appears, 
therefore, quite plausible to add salt to the infant's food 
(ordinary table-salt: !NaCl), which is likely to be trans- 
formed into HC1 in the infant's stomach. • 

The Feeding of Sick Children. — The method of feed- 
ing here is entirely different from feeding in health. No 
definite rules can be laid down as to the quantity or the 
quality, or the interval required for feeding; for example, 
if an infant suffering with dyspepsia will vomit, and have 
large, cheesy curds in the stools, and have anorexia, such 
an infant requires food that is far more diluted with water 
than heretofore. If, let us say, an infant, two months old, 
suffer with dyspeptic disturbance, and receives 2 parts of 
milk and 3 parts of water, such an infant should be given 
1 part of milk with 3 parts of water, to see if the dys- 
peptic condition cannot be modified. If no improvement 



THE DIET OE A NURSING MOTHER. 73 

is noted after several days of such feeding then it is wise 
to substitute barley-water instead of plain water, and thus 
see if the digestibility of the casein cannot be improved. 
If, however, no improvement is noted, then a good plan 
is to resort to predigested foods. It is in this class of cases 
that peptonized foods are so advantageous; but, if milk 
is badly borne, then it should be diluted with dextrinized 
gruels. 

The Diet of a Nursing Mother. 

Immediately after the birth of the child the exhausted 
condition of a woman following labor will certainly call 
for rest; hence sleep is imperative, after which some form 
of stimulation is required. This can best be accomplished 
by giving at intervals of several hours good wholesome 
food, as broth of chicken, or beef-broth, weak tea, or 
strained gruel. It is unnecessary to state that each 
woman's case and her former habits must be taken into 
consideration; and thus, if the labor has been normal, 
the nourishment will certainly stimulate the now of milk. 
Great care, however, must be given to the usual irritable 
stomachs in this condition, and, if warm liquids are not 
well borne, then cold drinks, like buttermilk, koumiss, 
matzoon, or iced tea, should be employed. In some in- 
stances ice-cream will aid nutrition and allay gastric irri- 
tability. If the pelvic condition is normal, then it is wise 
not to give solid food for the first three days, but, rather, 
stimulate the milk-glands by giving meat-broths, farina- 
ceous gruels, and by all means milk. Zwieback soaked 
in milk or in tea is highly nutritious and easily digestible. 
Other nutritious foods are calf s-foot or chicken jelly. 

After the third day — if the pelvic organs are normal 
— it is wise to consider the action of the bowels. If the 
bowels have not moved by this time, then buttermilk 
added to the diet or some stewed prunes or baked apples 
or stewed peaches, or grapes, will aid in establishing a 
movement of the bowels. 



74 



INFANT-FEEDING. 



If the milk is scanty and the bowels have not acted, 
then the best remedy is a large tablespoonful of castor-oil, 
modified to suit the taste by the addition of either orange- 
juice or lemon-juice, or by adding several drops of the 
ordinary spirit of peppermint. After the bowels have 
been evacuated and the general condition warrants it, 
then a diet consisting of the following is indicated: — 



Beeakfast, 7 to 8 A.M. 



Hominy and Milk. 
Farina and Milk. 
Eice and Milk. 
Oatmeal and Milk. 
Germea and Milk. 
Cream of \Ykeat and Milk. 
Some Stewed Prunes, Tigs, 

or Peaches. 
Stewed Apples. 
Oranges. 



Grapes. 

Soft-boiled Eggs. 
Poached Eggs. 
Eggs on Toast. 
Coffee and Milk. 
Tea and Milk. 
Cocoa and Milk. 
Toast and Butter. 
Stale Bread (2 days old), 
with Butter. 



I do not advise meat or fish in the mornine;, unless 
the nursing mother has always been accustomed to this 
form of diet. 



Ltj^ch, 12 to 1 p.m. 

Some soup, made from meat — either veal, beef, mut- 
ton, lamb, or chicken — and containing also some rice, bar- 
ley, farina, sago, or hominy; it should not be highly sea- 
soned, and should not be strained. 

Eish, boiled or fried, and all shell-fish, particularly 
oysters, are very nutritious during the milking period. 

If the appetite warrants it, then a piece of steak or 
chop, roast beef, chicken (white meat only), or raw 
chopped meat, with bread and butter, is very nutritious. 

Some fruit. 



the diet of a nursing mother. 75 

Evening, 6 to 7 p.m. 

A bowl of Oatmeal Gruel. Junket. 
A drink of milk. Cup of Tea. 

Farina Pudding. Eggs, if desired. 

Rice Pudding. Meat, if in the habit of eat- 

Cornstarch Pudding. ing it in the evening. 

Some Oysters (stewed). 

For Thirst. — Cool, filtered water or the alkaline 
waters, like Seltzer and Apollinaris. 

If the milk is scanty, the flow can be stimulated by 
drinking a cup of hot broth, made from beef, chicken, 
veal, lamb, or mutton, several minutes before putting the 
child to the breast. 

Alcoholic Drinks. — If a woman is in the habit of 
drinking beer or wine, then it is unwise to discontinue the 
use of alcoholics in moderate quantities, while she is nurs- 
ing. I have seen a great many women, whose flow of milk 
was scant, who immediately secreted an abundance of 
milk after partaking of a glass of beer or ale or porter 
with their meals for several days. Beer has a decided 
laxative effect, and this in itself is rather an advantage 
for those nursing mothers having a tendency to constipa- 
tion. So, my rule, therefore, would be to insist on ab- 
stinence from wine and beer unless the patient has been 
in the habit of taking it formerly. 

THINGS TO BE AVOIDED BY A NURSING WOMAN. 

Onions. Large quantities of pota- 

Garlic. toes. 

Cabbage. Butter and fat, except 

Powerful salts (Rochelle, moderately. 

Glauber, Epsom). Candies and too much 

Ethereal oils. »- sweets. 



CHAPTER XII. 

Wet-hitesb. 

If tlie infant's own mother cannot nurse her child, 
then we can and should try to secure a wet-nurse. 

The wet-nurse must be carefully examined, as well 
as her child, for the presence of syphilis. I beg to refer 
to a short paper on this subject, published in the Amer- 
ican Medico-Surgical Bulletin in January, 1894. 

1. Never have a baby fed by the milk of its mother 
if the latter suffer with general debility or tuberculosis. 
Extremely nervous mothers should not nurse their babies. 

Syphilitic babies (hereditary) can only be nursed by 
their own mothers, owing to the risk of infecting the wet- 
nurse. In such cases very frequently the life of the child 
is dependent on its being nursed by its mother. 

The following general rules may be noted: — 

(a) The return of menstruation is no contra-indication 
to the continuation of nursing. 

(b) The moment a woman is pregnant nursing should 
be stopped. 

(c) Children should not be nursed at night unless for 
some special reason. 

(d) Weaning should take place gradually, and only 
in the eighth to the tenth month. 

(e) It is understood that weaning should not be com- 
menced during the hot summer weather. 

The main factor in determining the time of weaning 
is "weistfriner." Children must be weaned when, although 
in perfect good health, they remain below normal weight. 

(/) Prolonged nursing will induce rachitis. 

2. If, for various re^ons, a child cannot be nursed 
by its own mother, we then resort to the wet-nurse. 

(76) 



WET-NURSE. 77 

(a) She must be carefully examined as to her phys- 
ical condition; tuberculosis, all chronic disorders and 
diseases would prevent proper nursing. Hereditary 
nervous troubles, epilepsy, or syphilis would exclude 
nursing. 

(b) It is a good point to try to procure a wet-nurse 
suckling a child about as old as the one we wish her to 
nurse, although it is quite common to find nurses who 
have older children than the one they wish to nurse and 
to find the latter doing well. 

(c) The proof of the usefulness of the wet-nurse is 
the condition of the baby after some time. If the child 
thrives, it will increase in weight. Hence scales must be 
frequently used. 

DIET OF A WET-NURSE. 

The diet given for a nursing mother can also be used 
as a guide in choosing the diet for a wet-nurse. The 
greatest care, however, must be bestowed on the 

Manner of Living. — If a wet-nurse was formerly a 
servant, or worked out-of-doors and is suddenly taken into 
this new mode of life and given charge of a baby, she 
must have proper exercise, or she will very soon secrete 
milk totally unfit for an infant, and, as a result, the child 
will probably have severe colic and irregular, cheesy 
stools; will vomit excessively, and will not gain suffi- 
ciently in weight. It is, therefore, important to try to 
adapt a wet-nurse to the same condition as existed prior to 
her pregnancy, so that both her manner of living and, 
chiefly, her diet shall not be different. 

Proper Rest. — To be equal to her task a nurse must 
be given plenty of sleep, if it is at all possible. 

Adriance, in the Archives of Pediatries, says: — 

1. Excessive fats or proteids may cause gastrointes- 
tinal symptoms in the nursing infant. 

2. Excessive fats may be reduced by diminishing the 
nitrogenous elements in the mother's diet. 



78 INFANT-FEEDING. 

3. Excessive proteids may be reduced by the proper 
amount of exercise. 

4. Excessive proteids are especially apt to cause gastro- 
intestinal symptoms during the colostrum period. 

5. The proteids, being higher during the colostrum 
period of premature confinement, present dangers to the 
untimely-born infant. 

6. Deterioration in human milk is marked by a re- 
duction in the proteids and total solids, or in the proteids 
alone. 

7. This deterioration takes place normally during the 
later months of lactation, and, unless proper additions are 
made to the infant's diet, is accompanied by a loss of 
weight, or a gain below the normal standard. 

8. When this deterioration occurs earlier, it may be 
the forerunner of the cessation of lactation, or well- 
directed treatment may improve the condition of the 
milk. 

Methods of Changing the Ingredients in 
Woman's Milk. 

Rotch gives a condensed table for these changes as 
follows : — 

To Increase the Total Quantity. — Increase the liquids 
in the mother's diet, especially milk (malt-extracts may 
be helpful), and encourage her to believe that she will be 
able to nurse her infant. 

To Decrease the Total Quantity. — Decrease the liquids 
in the mother's diet. 

To Increase the Total Solids. — Shorten the nursing 
intervals, decrease the exercise, decrease the proportion 
of liquids, and increase the proportion of solids in the 
mother's diet. 

To Decrease the Total Solids. — Prolong the nursing 
intervals, increase the exercise, and increase the propor- 
tion of liquids in the mother's diet. 



WET-NURSING. . 79 

To Increase the Fat. — Increase the proportion of meat 
in the diet. 

To Decrease the Fat. — Decrease the proportion of 
meat in the diet. 

To Increase the Proteids. — Decrease the exercise. 

To Decrease the Proteids. — Increase the exercise up 
to the limit of fatigue for the individual. 

It is wise in all cases of disturbed lactation, whether 
in maternal or wet- nursing, to make efforts in accordance 
with these rules to produce a milk that is suitable for an 
infant who is not thriving, before changing to any other 
method of feeding. 

Wet-nursing. 

It is an established fact that the best possible food 
for an infant is breast-milk. Where the mother of an 
infant is prevented from nursing her child, the next thing 
to be considerd is wet-nursing. That nursing a child is 
an advantage to the mother is a well-known fact, inas- 
much as it influences the contraction of the uterus and 
stimulates the circulation. Contrary to the belief that 
nursing a child is detrimental, and contra-indicated in 
women whose lungs are weak and who have a tendency 
to the development of tuberculosis, it does them no harm, 
and, indeed, seems to do them good. This statement is 
borne out by the experience of Dr. Heinrieh Munk, of 
Karlsbad, Austria, a specialist for diseases of women. 

In Austria the State supports public institutions for 
lying-in women. They are kept there and confined gratis, 
and remain about fourteen days. They are admitted into 
these hospitals in the last months of pregnancy. Vienna 
usually has about 300 women on hand. Prague con- 
stantly has 100 women in this condition, who are utilized 
for the purpose of instruction to physicians and midwives. 

In Prague there are about 3000 women confined 
annually, and these women are put into the foundling- 



80 INFANT-FEEDING. 

asylum. There they remain until they procure a place 
as a wet-nurse or as long as their services are needed in 
the asylum. When wet-nurses are taken from the found- 
ling-asylum, it is a frequent occurrence to have those 
remaining therein nurse at least two children, and fre- 
quently three, at one time. In this manner they dispense 
gradually with these wet-nurses without hurting the re- 
maining children. Many children die, some of them 
intrapartum in operative confinements, and the women 
(mothers of such children) are then utilized for wet- 
nursing. It is a rule to keep the children in the asylum 
until they have attained a little over four kilogrammes 
(about 9 pounds), and they are then put out for further 
feeding (artificial feeding), for which the city pays about 
12 florins a month ($5.00). The children remain usually 
until they are six years old, and are then given back to 
their own mothers. Many of these children die, others 
are adopted by those who have reared them, but the 
greater portion are taken back by their own mothers. In 
Vienna there are about 10,000 confinements annually in 
the public institution. There are a great many cities 
in Austria — like Innsbruck- Olmutz, Brunn, Linz, and 
Klagenfurt — where there are at least 200 confinements 
annually. In Vienna a wet-nurse receives 30 florins per 
month, for which she is sent (railroad expenses paid) to 
whoever requires her services. She is taken on trial for 
fourteen days, to see if she is adapted for her place. 
A wet-nurse can be procured by sending a telegram and 
a money-order any day during the year. The customary 
wages are from 12 florins upward per month. Each wet- 
nurse is carefully examined by the professor before she 
is sent away. A great many families do not care to take 
a wet-nurse from an asylum, as they are usually women 
in the lowest walks of life, and prefer, therefore, to take 
a woman who has been married. For this purpose there 
are wet-nurse agencies, duly licensed. These will supply 
wet-nurses, and usually take orders in advance; thus a 



WET-NURSING. 81 

wet-nurse may be reserved. Such wet-nurses cost much, 
more, and those from one special region — Iglau in Mahren 
— receive from 20 to 50 florins monthly. 

The empress took for her own use a wet-nurse from 
Iglau (a married woman), and the Princess of Bulgaria 
took a wet-nurse from Iglau for her last child. Not only 
Iglau, but the whole region, is renowned for its excellent 
quality of wet-nurses. The Bohemian and Mahren nurses 
have very good mammas. They seem to love the children 
intrusted to them. 

While it is a rule that a wet-nurse should be taken 
for a baby of the same age as that of her own, frequently 
wet-nursing of an infant at birth by a wet-nurse whose 
baby is three months old has not been followed by any 
bad results. 

In New York we are at a decided disadvantage re- 
garding wet-nurses. As no licensed agencies exist, a few 
people having so-called influence procure wet-nurses by 
friendship, or something similar, from superintendents 
and house physicians where obstetrical work is done. 

Thus we find ourselves at the mercy of some people 
who traffic in wet-nurses for a fee, usually five dollars, 
and who do not stop at anything to attain their own selfish 
ends. 

Time and again have I sent for a wet-nurse to an 
agent who, instead of giving me a healthy wet-nurse, tried 
to induce me to use women having colostrum-milk for 
an infant in which such milk would have proved disas- 
trous. 

In another instance, only recently, I procured a wet- 
nurse from an agent who sent me one 17 years old, who 
had had a premature birth, "evidently an abortion," and 
whose milk was typical thin water, with here and there 
a fat-globule, when examined under the microscope. 

At other times some of the finest specimens of wet- 
nurses have also been procured from the same agent. 

It is a pity that we have no municipal control for what 



82 INFANT-FEEDING. 

the writer considers one of the most valuable adjuncts to 
our maternal feeding, and such control would also regu- 
late the supply to such unlimited number that modern 
arrogance on the part of the wet-nurse would probably 
disappear. 

The prices paid in New York are from twenty to 
thirty dollars per month and board, and this price pro- 
hibits many an infant from securing the benefits of 
Nature's food. Let ns hope for municipal regulation. 20 

Weaning, and Feeding from One Year to 
Fifteen Months. 

Weaning should take place gradually between the 
eighth and tenth months. In some instances it is advis- 
able to commence weaning a child much sooner; for ex- 
ample, when there is a deficiency in the supply of milk 
or owing to ill health of the infant's mother. This I 
have already mentioned in the section on "Mixed Feed- 
ing." 

Weaning is imperative when the infant's mother is 
pregnant, although it is advisable to use great caution if 
it occur in midsummer. In a case of this kind the better 
plan would be to have a specimen of the breast-milk ex- 
amined by a chemist, and, if the same be found deteri- 
orated in quality, then the judgment of the physician 
must prevail as to the advisability of continuing or dis- 
continuing the nursing. My rule has been not to wean 
during the summer months. 

The main points have already been mentioned in this 
chapter under "Wet-nurse." 

Weaning should not be attempted suddenly. Thus, 
it is better to commence weaning gradually, by withdraw- 
ing the breast in the morning and substituting a bottle 
for that meal. Following this meal we can again nurse 



20 The attention of the Department of Health has been directed 
to this condition in New York. 



WEANING, AND FEEDING AFTER WEANING. 83 

the child at the breast for two feedings, and substitute a 
bottle for its fourth meal instead of the breast. In this 
manner we can feed the child with a bottle in the morn- 
ing, to be followed in three or four honrs by the breast, 
then at the next feeding again nurse the child, and this 
to be followed in three or four hours by the bottle: — 

8.00 a.m Bottle. 

11.30 a.m Nursing. 

3.00 p.m Nursing. 

6.30 p.m Bottle. 

10.00 p.m Nursing. 

In this manner we can see just how the food is as- 
similated, and also study the individual peculiarities of 
the baby. Some children are very hard to wean, and it 
will require great tact and patience to successfully cope 
with this condition. In consultation I recently saw a 
child which, on being removed from the breast, absolutely 
refused to take the bottle, and when fed with a spoon the 
child would spit out its food. After three or four days 
of this unsuccessful weaning the physician attempted 
more heroic methods, and insisted on isolating the child 
from the wet-nurse for tw T elve consecutive hours. This 
infant refused to take food even after that time, and then 
it was that I was summoned. We decided to give pep- 
tonized milk, alternating with peptonized yolk of egg by 
means of rectal feeding. Thus, 1 ounce of milk and 1 
ounce of starch- water were injected, followed four hours 
later by the peptonized yolk of egg added to the starch- 
water. This method of feeding can be found de- 
scribed in detail in the chapter on "Rectal Feeding," 
and also in the chapter on "Feeding in Diphtheria In- 
tubation Cases." Thus we aimed to sustain life and 
avoid starvation. The rectal feeding was continued 
for two days more, when the child suddenly took the 
bottle. 



84 INFANT-FEEDING. 

In some cases forced feeding by gavage will be found 
useful. If the child holds its jaws firmly, the catheter can 
be introduced through the nasal passage, as described in 
the section on "ISTasal Feeding." 

I was called to see a perfectly healthy child, about 
9 months old, whose mother told me that "he would not 
take the breast." She was greatly chagrined, but all 
efforts at nursing him proved futile. The infant had 
weaned himself. Such cases of "self-weaning" are very 
rare. 

When weaning is successfully accomplished, then 
great care must be exercised, owing to the change in 
diet. It will be found that the slightest error in over- 
feeding or too frequent feeding will be rewarded by a 
severe attack of dyspepsia and the usual gastric disturb- 
ances, such as vomiting and fermentation in the stomach, 
causing diarrhoea and possibly colic. It will therefore 
be very necessary to exercise good judgment in the choice 
of both quality and quantity of food during the first 
month or two after weaning or until the stomach adapts 
itself to this new way of feeding. The amylolytic func- 
tion now being thoroughly developed, we can safely give 
cereals. 

TIME OF FEEDING. 

Excepting in rare instances, after a child is weaned 
it should not be fed oftener than once in four hours. The 
best time for feeding would be about 6 a.m., 10 a.m., 2 
p.m., 6 p.m., and 10 p.m. if the child is awake. This would 
give eight hours rest, and healthy children can be trained 
to sleep that length of time. 

The first bottle after sleeping should consist of 8 
ounces of pure cows' milk. 21 This would be the 6-a.m. 
feeding. 

Four hours later, or at 10 a.m., the infant should 



21 The best milk obtainable in this city is undoubtedly milk 
received in bottles direct from the dairy the same day of milking. 



WEANING, AND FEEDING AFTER WEANING. 85 

receive the white of a raw egg, fed with a spoon from 
a wine-glass, immediately before its bottle, which con- 
sists of:— 

Cows' milk 5 ounces. 

Barley-water 2 ounces. 

• At 2 p.m. our next feeding should consist of 8 ounces 
of pure cows' milk. I usually permit the infant to nibble 
on a small piece of the ordinary zwieback. 
The evening meal at 6 p.m.: — 

Cows' milk 6 ounces. 

Barley-water 2 ounces. 

The last feeding, at 10 p.m., if the child is awake, or 
at midnight should consist of 8 ounces of pure cows' 
milk. 

When milk is brought from the dairy there is a thick 
layer of cream on the top of the milk, which should be 
thoroughly mixed with the milk by shaking the bottle, so 
that the infant receives a thoroughly mixed milk contain- 
ing the same quantity of cream in each feeding. The 
milk should be mixed and the barley-water added to it. 
It is then poured into thoroughly clean bottles, which are 
stoppered with ordinary cotton stoppers. This can be 
found described in detail in the chapter on "Sterilization." 
This food is to be steamed for twenty minutes and then 
allowed to cool by placing the bottles in a refrigerator, 
but not on the ice. When ready for use each bottle is 
to be warmed to a temperature of about 100° F. for the 
feeding. If constipation follows the use of this diet, then 
a good plan is to substitute 2 ounces of oatmeal-water 
instead of the barley-water above mentioned. When the 
stools are regular and the child appears to be quite pale, 
then great good can be accomplished by adding 2 ounces 
of almond-milk instead of the oatmeal- or barley- water. 
The preparation of almond-milk can be found described 
in the "Dietary," to which I beg to refer my readers. If 



86 INFANT-FEEDING. 

a severe form of constipation, with cheesy curds in the 
stools, exists, then the milk should not be steamed, but 
fed in the "raw state." It is understood that it should 
be warmed to the body-heat before feeding to the infant. 
Instead of giving the white of egg every day I substitute 
either 1 or 2 ounces of a good beef-soup or chicken-soup 
or beef-tea and expressed steak-juice, and feed this quan- 
tity immediately before the 10-a.m. bottle of milk. Xo 
distinct change of food will be necessary until the child is 
twelve or fifteen months old, when I am in the habit of 
giving either 1 / 2 saucer of oatmeal-gruel with some butter 
or some hominy and butter in addition to a morning 
bottle. In the evening, when the child arrives at this age, 
a half-dozen teaspoonfuls of junket can be fed before the 
evening bottle of milk. When a child is over one year 
or about fifteen months old, instead of giving water for 
thirst I frequently give prune-water made by boiling 
good fleshy prunes in water for one-half hour and strain- 
ing off the liquid. When oranges can be procured, one 
or more teaspoonfuls of orange-juice can be given with 
advantage. Apple-sauce can also be given. Thus, my 
plan consists in giving each one of these foods on different 
days. Just at this period the addition of several tea- 
spoons of Mellin's food has been found very beneficial. 
Owing to gastric derangements, it will be found necessary 
to frequently discontinue milk entirely. At such times 
the use of the milk-foods — such as Xestle's food — has 
proved very beneficial. When diluting milk with cereals 
like barley-water, rice-water, sago-water, flour-ball and 
water, it is always better to dextrinize the diluents. This 
dextrinization has a decided effect on the casein, inasmuch 
as it splits up the curd, rendering it finely flocculent as 
it is found in human milk, and it is especially indicated 
in the period of weaning after the stomach has been ac- 
customed to breast-milk and is suddenly forced to digest 
cows' milk containing a more rubbery and heavier casein, 
or curd. 



FEEDING AFTER WEANING. 



87 



1. Fruits < 



2. Cereals 



Diet After the Period of Weaning. 

The following dietary, one of each course, is to be 
given to a child one and a half to three years old : — 

BREAKFAST, 7 TO 8 A.M. 

Sliced apple with cream. 

Baked apple or apple-sance. 

Sliced banana with cream. 

Sliced peaches with cream. 

Oranges. 

Fleshy prunes. 

Grapes. 

Hominy. 

Farina. 

Oatmeal. 

Cream of wheat. 

Germea. 

Indian (or corn) meal pudding. 

Wheaten grit. 

A soft-boiled egg. 
A scrambled egg. 

4. Water, cocoa, or chocolate to drink. 

5. Toast and butter, wheat-broad and butter, or grape- 

NOON MEAL, 12 TO 1 P.M. 

1. Soup made with lentils or split peas, meat, and 
vegetables, but not highly seasoned. Thicken soup by 
adding either sago, farina, barley, or rice. The last should 
be omitted if severe constipation exists. 

f Broiled fish; white meat only. 
Raw scraped steak. 

2. Meats J Broiled to P sirloin ' 
| Broiled tenderloin. 

Lamb chops. 

(^ Breast of chicken. 



3. Eggs 



88 



INFANT-FEEDING. 



Spinach. 
Mashed potato. 

3. Vegetables J ^ked Potato, 
btewed corn. 



Mashed peas (without skins). 
[ Cauliflower. 

4. If the appetite warrants it, some fruit mentioned 
in the breakfast list may be given. 

EVENING MEAL (LIGHT) 5.30 TO 6.30 P.M. 

r Crackers and a bowl of milk. 

_ -r n Bread and a bowl of milk. 

1. Luncheon < ~ ; , , , - .,, 

| (Justard and a glass oi milk. 

[ Junket and a glass of milk. 

Cornstarch. 
Tapioca. 

2. Puddings <J Rice. 
Farina. 
Zwieback. 

3. Oysters or fruit. 



CHAPTER Xni. 
Management of Woman's Nipples. 

the management of the nipples befoee the 
baby is bobn. 

It is very important during the last few months of 
pregnancy to devote considerable time and attention to 
the condition of the nipples. If these be found long 
and round, well projecting, then it is advisable to try to 
harden them, because the irritation from the child will 
cause considerable trouble unless we seek to prevent this. 




Fig. 15. — Nipple-shield for Relief of Tender Nipples. 

For this purpose wash, in winter, with lukewarm water 
to which some alcohol has been added (2 teaspoonfuls 
of alcohol to a cup of lukewarm water). In summer cold 
water will be found more agreeable, using the same quan- 
tity of alcohol. If the nipples are very small and flat, 
and do not protrude properly, then suction by means of 
a breast-pump, applied directly over the breast, will draw 
them out. In some instances an ordinary clay pipe 
which has a smooth bowl, the bowl to be laid over the 

(89) 



90 INFANT-FEEDING. 

nipple and the stem to be sucked or drawn, is saticfac- 
tory. This is to be repeated every few days. A few 
minutes of drawing out will suffice until' the nipples are 
sufficiently prominent. Biedert 22 gives the following 
prescription for hardening the nipples: — 

Tannic acid 1 teaspoonful. 

Red wine 8 ounces. 

If red wine is not handy, then substitute brandy in 
its stead. This is to be applied after thorough washing 
with soap and water, and removing crusts, if they are 
present. 

TENDER NIPPLES. 

If, while nursing, the nipples crack and blood oozes 
from them, or if, from irritation of the child's gums 
biting them, the nipple is sore, then it is a good plan to 
allow the child to nurse through a nipple-shield. (See 
Fig. 15.) 

Nipple-shields can be used during the nursing act, 
and immediately thereafter the following salve can be 
smeared on the nipples: — 

IJ Zinc oxide, 1 drachm. 
Vaselin, 1 ounce. — M. 

BREAST-PUMP. 

The breast-pump (Figs. 16 and 17) is a valuable ad- 
dition to the nursery. It should be kept scrupulously 
clean by immersing it in boiling water containing a pinch 
of table-salt. In drawing a specimen of breast-milk for a 
chemical examination the breast-pump is very useful. If 
an infant is ill and refuses the breast, — as, for example, 
if it has rhinitis or cold in the head, nasal obstruction, 
preventing it from breathing while the nipple is in its 
mouth, — it generally will take the breast and immediately 



22 "Kinderernaehrung," fourth edition, 1900, page 110. 



BREAST-PUMP. 



91 



let go of it again. If the breast-pump is properly applied, 
and the required quantity of milk drawn off, the infant 
can frequently be fed slowly with a spoon. 




Fig. 16. — Breast-pump. 

In a serious condition, — as, for example, in a severe 
case of pneumonia with loss of appetite, — the life of the 
child may depend on forced feeding. This will be de- 




Fig. 17. — Breast-pump. 

scribed in the section on "Gavage." It is very important 
to have the cup or any other receptacle into which we 
draw the breast-milk properly sterilized; otherwise the 
breast-milk will be infected in the same manner as has 
been described in detail in the sections on "Cows' Milk" 
and ''Bottle-feeding." 



CHAPTER XIV. 

Infant's Weight. 

When a child develops normally, at either breast- 
or bottle- feeding, then it increases from 6 to 8 ounces 
each week for the first two or three months. This gain 
is slightly lessened toward the end of the fifth or sixth 
month; bnt if a child thrives, then its gain, be it ever 
so small, must be steady from week to week. We have 
distinct data on which to base our calculations, and any 
variation from the normal should be carefully investi- 
gated. If a child is breast-fed, and suddenly ceases to 
gain in weight, then a chemical examination of the breast- 
milk is imperative to know just what ingredient is want- 
ing. If the child is bottle-fed, and the weight does not 
increase, then the formula is improper and frequently the 
addition of a larger quantity, or sometimes the changing 
of the quality, — as, for example, several ounces of cream 
instead of several ounces of milk, — will give the baby the 
requisite amount of food. 

Table Showing the Gain in a Healthy Infant 
Fed at the Breast. 



ISTormal weight at birth, 


Gain at the end of the first 


7 lb. 


week, jSTone. 


Weight when 2 weeks old, 


Gain at end of 2 weeks, 


7 lb. 6 oz. 


6 oz. 


Weight when 3 weeks old, 


Gain at end of 3 weeks, 


7 lb. 14 oz. 


8 oz. 


Weight when 4 weeks old, 


Gain at end of 4 weeks, 


8 lb. 6 oz. 


8 oz. 


(92) 





infant's weight. 93 

The vital factor is certainlv the general condition 
of the infant, whether it is bright and playful, sleeps 
quietly, and the condition of its stools. AVhen the latter 
are normal as to color and frequency, then we may be 
sure that the baby is thriving. 

During the second month the infant should gain 
about 8 ounces per week; roughly speaking, an ounce 
per day is a good average. 

During the third month a child should gain an ounce 
per day, or about 2 pounds per month. 

After the third month, an infant usually gains about 
3 to 4 ounces per week; so that if a child has doubled 
its weight at the end of the fifth month, such a child 
should be considered normal, if the other conditions 
warrant such an opinion. An infant should weigh three 
times its weight at birth by the end of its first year. 

Taking seven pounds as the average weight for an 
infant at birth, it should weigh 14 pounds at the end of 
five months and 21 pounds at the end of its first year. 

Weighing Immediately After Nursing to Determine 
the Quantity of Milk an Infant has Taken. — TThen 
scanty milk-supply is suspected in either the nursing 
mother or in a wet-nurse, then we can, in some instances, 
resort to weighing immediately after the baby has nursed. 
It is understood that the child must be weighed both 
immediately before nursing and then immediately after 
nursing. The difference in weight is the amount of milk 
swallowed. 

While this may serve in some cases, the author has 
not found it very practical, and cannot recommend it, 
excepting in rare instances. 

It is well known that an infant whose stomach is 
filled requires rest after nursing, and the less it is 
handled the less is the chance for expelling its food. 
Thus, my advice is not to handle or fumble with a child 
after nursing, but rather aid Nature in resting an infant 
than to try to provoke vomiting by unnecessary handling. 



94 



[NFANT-FEEDING. 



Difference in Weight Before and Immediately After 
Nursing. — An infant should weigh, if under 3 months 




Fig. 18. 



old, 3 ounces more after nursing, and in older children, 
5 to 6 months, it should weigh at least 6 ounces more 



after suckling. 



WEIGHT-CHART FOR AX IXFAXT. 



95 



Weight-chart eor ax Ixfaxt. 



Week 

AFTER 

Birth. 


Date ; We ^ ht 

\*5® H WITH 

■ L - ^- Clothes 


Weight 

OF 

Clothes 


Body- 
weight 


Kl>~D OF 

Food ; Quan- 
tity and 
Frequency 
of Feeding. 


Stools 


On the 
birthday. 
After 

1 week . . 

2 weeks . 

3 weeks . 

4 weeks . 












- 


After 

5 weeks . 

6 weeks . 

7 weeks . 

8 weeks . 














After 
9 weeks . 

10 weeks . 

11 weeks . 

12 weeks . 














After 

13 weeks . 

14 weeks . 

15 weeks . 

16 weeks . 














After 

17 weeks . 

18 weeks . 

19 weeks . 

20 weeks . 














After 

21 weeks . 

22 weeks . 

23 weeks . 

24 weeks . 














After 

7 months. 

8 months. 

9 months. 

10 months. 

11 months. 

12 months. 















96 



INFANT-FEEDING. 



Properties of Human Milk. 



Appearance. 
Specific Gravity. 

Reaction. 
On Boiling. 
Coagulates. 



Bluish, semitransparent, no odor, sweetish. 

1.26 to 1.36. 

^ Amphoteric, relation of alkalinity and acid- 
( ity as 3 to 1. 

Does not coagulate, and forms a very thin, 
hardly-perceptible skin. 

At ordinary temperature after several 
hours. 



Coagulates on addi- 
tion of Lab-fer- 
ment. 



Coagulates imperfectly in small isolated 
flakes, which do not precipitate as a uni- 
form eoagulum. 



Fat. 



Yellowish white, resembling cow-butter. 
Specific gravity at 15° C, 0.966. Melts 
at 34° C. 



Varieties of Fat. 



Butyrin, palmitin, stearin, olein, myristin, 
caproin. 



Behavior of Various $ Few volatile acids. More than half of the 
Acids. ( non-volatile consist of oleic acid. 



Milk-plasma Casein. 



r Difficult to precipitate with acids and salts. 
The precipitate redissolves in excess of 
acids. During pepsin digestion there is 
no pseudonuclein produced. 



f Lactalbumin and lactoglobin; relation of 

n •*• * casein to albumin, 0.5 to 1.2 or 1 to 2.4; 

Composition of Albu- _| of the L3 per cent a ]btimin, there are 64 

minoids. parts of casein, and 37 parts of globulin 

t and albumin. 

~ ,., ( Less solids than in cows' milk, especially 

Sollds - I CaO- PA. 



Quantitative Analy- f Wat 8741 albuminoids, 2.29; fat, 3.78; 
Soxhfet ^ 1 milk - su g ar > 6 - 21 ; solids, 0.31. 



Bacteria. 



Usually sterile, rarely staphylococcus albus 
and aureus. 



PROPERTIES OF COTYS MILK. 



97 



Properties of Cows' Milk. 



Appearance. 
Specific Gravity. 

Reaction. 

On Boiling. 

Coagulates. 

Coagulates on addi- 
tion of Lab-fer- 
ment. 

Fat. 

Varieties of Fat. 



Behavior of Various 
Acids. 



Milk-plasma Casein. 



Composition of Albu- 
minoids. 



Solids. 

Quantitative Analy- 
sis, according to 
Soxhlet. 



Bacteria. 



{ 



Opaque white or whitish yellow, in thin 
layers bluish white, slight odor, faintly 
sweet. 

1.28 to 1.36. 

Amphoteric; relation between alkalinity 
and acidity, 2 to 1; Soxhlet maintains 
that cows' milk contains three times the 
acidity of human milk. 

Does not coagulate and forms a skin con- 
taining casein and lime-salts. 

Coagulates very soon, owing to lactic-acid 
formation. 

Coagulates to a solid mass at body-tem- 
perature, from which a yellowish fluid 
can be expressed. 

Yellowish-white mass. Sp. gr. at 15° C, 
0.949 to 0.996. 

Palmitin, olein, stearin, myristin, caprilin, 
caprin, caproin, butyrin, laurin, lecithin, 
cholesterin, and yellow coloring matter. 

Volatile fatty acids, about 70 per cent.; 
not volatile, 0.3 to 0.4 per cent, of oleic; 
the remainder consists of palmitic and. 
stearic chiefly. 

Easy to precipitate with acids and salts; 
excess of acid does not dissolve; belongs 
to the nucleo-albumin group. 

Less lactalbumin and globin; the largest 
portion of the albuminoids is casein. 
Relation of casein to albumin, 0.3 to 3.0, 
or 1 to 10. 

Cows' milk contains more solids than hu- 
man milk. 

Water, 87.17; albuminoids, 3.55; fat, 3.69; 
milk-sugar, 4.88; solids, 0.71. 

Contains all milk bacteria, frequently also 
pathogenic bacteria, as typhoid, diph- 
theria, and tubercle bacilli, etc. 



CHAPTER XV. 

Raw Cows' Milk. 

The ideal cows' milk is clean, raw milk. By this is 
meant milk free from all possible contamination. Such 
milk should be obtained from a stable having all modern 
hygienic surroundings. If greater attention were be- 
stowed on the condition of the cow, the cow's udder, the 
stable, the bucket, the hands of the milker, then less ster- 
ilization and pasteurization would be necessary. For let 
it be distinctly understood that certain chemical changes 
are brought about in milk when it is steamed, be it in 
the process of sterilization or pasteurization. Neither 
pasteurization nor sterilization adds to the digestibility of 
milk. Indeed, clinical experience has demonstrated the 
fact that raw milk, known in some places as certified milk, 
in the milk-laboratories in New York City as guaranteed 
milk, is more easily assimilated, as proved by the condi- 
tion of the stools as well as the gastric digestion. 

Nature has given us a good example of how milk 
should be fed to an infant. Breast-milk is certainly raw 
milk, and is served to the infant at the temperature of 
the body. Not only does boiling or steaming milk pro- 
duce chemical changes in the albuminoids, but it renders 
the process of digestion much more difficult, and thus it 
is that most infants taking boiled milk suffer with con- 
stipation. This is not so, however, in the case of infants 
fed on raw milk. 

When sterilized milk or pasteurized milk is found 
to disagree with children, raw milk may sometimes be 
easily assimilated. Thus it will be found that, while 
boiled milk or sterilized or pasteurized milk, given either 
whole or with its proper dilution to suit the various ages, 
(98) 



RAW COWS' MILK. 99 

will provoke constipation, by substituting raw milk in- 
stead of the heated milk the same will be more easily 
assimilated. The author has frequently noted decided 
antiscorbutic properties in fresh raw milk. In children 
with pronounced rickets, and even scurvy, the withdrawal 
of sterilized or other milk and the substitution of fresh 
raw milk will work surprising changes. 

Biedert, in his fourth edition of 1900, page 184, 
states that he has followed Escherich and Epstein, who 
recommend giving full milk to children at birth. In 
France Budin and H. de Rothschild, and more recently 
E. Schlesinger, in Germany, have given undiluted milk 
to both sick and well children as a substitute for breast- 
milk. Biedert claims to have seen good results in some 
instances, but cannot recommend whole milk, as a rule, 
for feeding children. Marfan, another advocate of pure- 
milk feeding, believes that milk should be diluted until 
the fourth or fifth month, but later he advises pure-milk 
feeding. Schlesinger, of Breslau, while giving pure 
milk gives a longer interval between the meals. That 
the greatest possible success is not achieved by this method 
of feeding in France can be judged by the statement of 
Marfan while discussing the subject of athrepsia. He 
says: "Wa jamais vu Vathrepsie confirmee se terminer 
favor •ablement." Thus it seems that even we have much 
better results than the French, for there are certainly a 
great many children who can and will digest a diluted 
milk, and thin milk- and cream- mixtures, as shown by 
their stools, their sleep, and their increase in weight. 
These same children with enfeebled digestive functions 
will invariably show gastric disturbances, — such as vom- 
iting, colic, constipation or diarrhoea, restlessness, sleep- 
lessness, — and will cry continually; besides, they do not 
increase in weight. This method of feeding has been 
tried over and over again, and we are compelled to dis- 
continue the heavier food, consisting of pure milk, and 
to substitute a light food, consisting of diluted milk. 
LofC. 



100 infant-feeding. 

Fresh Kaw Milk. 

Just as the medical profession, and to some extent 
the laity, have become thoroughly impressed with the 
idea that milk should be boiled before being used, to 
insure the destruction of the microbes which it contains, 
Dr. Freudenreich comes forward with a series of experi- 
ments, by which he claims to prove that fresh raw milk 
possesses remarkable germicidal properties. According to 
his experiments, the bacillus of cholera, when put into 
fresh cows' milk, dies in an hour, the bacillus of typhoid 
fever succumbs at the end of twenty-four hours, while 
other germs die at the end of varying periods. 

Milk which has been exposed to a temperature of 
131°. F. loses its germicidal properties. Milk which is 
four or five days old is also devoid of microbe-killing 
power. 23 

Raw-Milk Assimilation. 

VasiliefT, 24 in an inaugural thesis of 1889, in St. 
Petersburg, details experiments made on six healthy in- 
dividuals, varying from 18 to 23 years of age, restrict- 
ing them for three days to a diet of fresh milk, and then 
for the three days following to boiled milk. The author 
claims that his experiments have proved that the assimi- 
lation of the nitrogenous principles of the boiled milk is 
considerably less than of fresh milk, although the differ- 
ence is less marked than in the case of the fats. Never- 
theless the faeces contain considerably more fatty acids 
after the administration of boiled milk than after the use 
of fresh milk. He therefore concludes that the nutritive 
value of boiled milk is much inferior to that of fresh 
milk. He explains these differences by the hypothesis, 



23 Bacteriological World, December, 1891; Journal of the Ameri- 
can Medical Association, February 27, 1892. 

24 Journal de Medecine, May 4, 1890; Therapeutic Gazette, June 
16, 1890. 



SCURVY. 101 

first advanced by Schmidt, that, by boiling, a part of the 
casein in cows' milk is transformed into hemialbnminose. 



Scurvy. 

A paper on "The Uses and Prospects of Pathology," 
delivered at the opening of the Section in Pathology at 
the recent annual meeting of the British Medical Asso- 
ciation, by Dr. W. Howship Dickinson, senior physician 
and lecturer on medicine at St. George's Hospital, states 
that a disease which presents itself as of chemical origin, 
if one due almost certainly to a specific deficiency in the 
constituents of the food may be so regarded, is scurvy, of 
which the chemical secret has apparently been so readily 
exposed that the chemical antidote ought to be almost 
within our grasp. The conditions which give rise to sea- 
scurvy are generally known. It is not probably as widely 
recognized that scorbutic affections are so common on 
shore, among infants brought up by hand, that this form 
of land-scurvy is scarcely less important. It is to be at- 
tributed to the exclusion of fresh milk by various arti- 
ficial preparations used in its stead. ISTot that these prep- 
arations are in themselves injurious, but they are insuffi- 
cient. 

Milk in its fresh state, and of good quality, whether 
from biped or quadruped, is antiscorbutic; preparations 
or sophistications of it are not so, or not so to a sufficient 
extent. Scorbutic hsematuria and scurvy-rickets are but 
too frequent consequences of this substitution. We know 
the broad result, which is enough for practice, but we do 
not know the isolated want. What does fresh milk con- 
tain which is so essential and so difficult to preserve? We 
no more know this than what there is in lemon-juice to 
be antiscorbutic, while neither citric acid, nor potash are 
so. The problem is attractive, like a puzzle; some day 
it will be solved, and then we shall wonder why it was 
not solved before. 



102 



1 X KANT-FEEDING. 



Raw Meat: its Beneficial Effect Experimen- 
tally Proved. 

Richet and Hericourt announced, at the meeting of 
the Paris Societe de Biologie, June 2d, that they inocu- 
lated a number of dogs with tuberculosis more than six 




Fig. 19. 




Fig. 20. 

months ago. One-third were fed with ordinary food, and 
all died in three or four weeks; another set with cooked 
meat, with about the same results, while the third group 
was fed exclusively with the raw meat, and all have sur- 
vived to date and are in good health. 



infant-feeding. 103 

Raw Muscle- juice Possesses Antitoxic Properties. 

A. Sicard 25 says the effect of "zomotherapy" — as 
Pichet calls bis experiments with 328 dogs inoculated 
with tuberculosis and then fed on raw meat — indicates 
that the raw muscle-juice has a specific antitoxic power 
in regard to the tubercle bacillus. The dogs survived, 
on an average, 300 days, and some for two and a half 
years, while the control animals all readily succumbed. 
Sicard discusses the various theories advanced to explain 
these facte, and suggests that it would be interesting to 
determine whether other food-elements (codliver-oil, for 
instance), administered to dogs and guinea-pigs in suffi- 
cient amounts, would have an inhibiting action on the 
evolution of experimental bacillosis; also whether forced 
ingestion of raw or dried meat would transform the cel- 
lular or humoral medium in animals and render them 
refractory to infection. 

Infant-feeding. 26 

It is impossible to go over the broad domain of arti- 
ficial feeding in the time usually allotted to a discussion 
and do justice to all the interesting papers presented. 
Let me, therefore, give you in brief what would be my 
personal views based on clinical experience. 

My first proposition in hand-feeding is: Secure the 
best possible cows' milk from a reliable dairy. The hy- 
gienic condition of the cows' stable should be in accord 
with modern sanitary laws ; so that the principle of steril- 
ization is applied to everything from the stable, to the cow, 
to the milker's hands, and to all utensils used in milking 
and transportation, exactly as given by Professor Bagin- 
sky in his paper, which I had the honor to read at the 



25 Presse Medicale (Paris), June 13th. 

26 Discussion on infant-feeding, Academy of Medicine, October 
18, 1900, by Louis Fischer, M.D. Archives of Pediatrics, January, 
1901. 



104 INFANT-FEEDING. 

meeting of the Section on Diseases of Children at Atlantic 
City, June, 1900. Summing up, then, asepsis — which is 
really nothing but absolute cleanliness — should be rigidly 
enforced. 

Second Proposition. — Imitate Nature in feeding, 
using raw milk. In this way we copy from Nature just 
what she has ordained for woman to feed, for it must be 
admitted that breast-milk (woman's) is raw milk. It is 
neither boiled, sterilized, nor pasteurized. AVhen the pre- 
cautions mentioned in my first proposition are carried out, 
there is no risk of infection. 

Do we ever stop to think how many millions of mi- 
crobes lie dormant in the gastrointestinal canal ready to 
reinfect the sterilized milk? My plan is to give pure milk 
(properly diluted or pure) if the age warrants, and merely 
warm it immediately before feeding it to the infant — 
temperature of 100° F. 

TTe know that a great many children fed on sterilized 
milk develop scurvy. The same is true of children fed 
on boiled milk. The reason is, Rundlett so ably says: 
"Changes take place not in the albumin, fat, nor sugar, 
but in the albuminate of iron, phosphorus, and possibly 
in the fluorin vital changes take place. These albumi- 
noids are certainly in the milk, derived, as it is, from tis- 
sues that contain them, and are present in a vitalized 
form, as proteids." 

On boiling, the change taking place is simply due 
to the coagulation of the globulin, or proteid molecule, 
which splits away from the inorganic molecule and thus 
renders it, as to the iron and fluorin, unabsorbable, and, 
as to the phosphatic molecule, unassimilable. This is the 
change that is so vital, and this only takes place when 
milk is boiled. 

It is evident that children require phosphatic and 
ferric proteids in a living form, which are only contained 
in raw milk. 

Cheadle says that phosphate of lime is necessary to 



INFANT-FEEDING. 105 

every tissue; no cell-growth can go on without earthy 
phosphates; even the lowest form of life — such as fungi 
and bacteria — cannot grow if deprived of them. These 
salts of lime and magnesia are especially called for in 
the development of the bony structures. 

Avoidance of Scurvy. — Since clinical experience has 
demonstrated that the prolonged use of sterilized and 
boiled milk will produce scurvy, and that improvement 
is immediately noted when raw milk is given or raw 
muscle-juice (beef-juice) or raw white of egg, added to 
fresh fruit-juices, does it not seem more plausible to com- 
mence feeding at once with raw milk rather than after 
scurvy or rickets is developed? 

There is a certain deadness, or, to put it differently, 
absence of freshness, in milk that has been boiled or ster- 
ilized, which causes disease in the infant just as the ab- 
sence of fresh meats and green vegetables is known to 
cause scurvy in the adult. 

GENERAL RULES FOR FEEDING INFANTS. 

Each child is a law unto itself, and its individual 
wants must be studied. One child will gain on the same 
mixture on which another will lose weight. The proof 
of the proper assimilation of food in any and every child 
will be the following: — 

The infant must appear satisfied after taking its bottle. 
There should be no vomiting nor severe colicky pains. 

The bowels must move (unaided) at least once or 
twice in twenty-four hours. The stools should be yellow- 
ish white and medium soft. 

The infant should sleep from four to eight hours at 
one time during the night. 

The weight must be taken regularly once a week. If 
an infant thrives it should gain at least from 6 to 8 ounces 
every week. "When the child's weight shows no increase, 
then study the reason, and by all means change the food; 
give more substantial food. 



10G INFANT-FEEDING. 

SUBSTITUTE FOR MILK IN DISEASES OF STOMACH 
AND INTESTINES. 

When milk disagrees and the infant's stomach will 
not tolerate the same, and vomiting is provoked, or when 
gastro-intestinal trouble arises, then milk must be stopped. 
At such times I have seen very good results follow the 
use of almond-milk (see "Dietary"). 

Dextrinization is successful in children having sub- 
normal gastric digestion. The author does not advise the 
dextrinization of food for healthy children, but only in 
feeble, ill-nourished, and weakened conditions. 



CHAPTEK XVI. 

Cows' Milk. 

Hammeesten 27 gives Konig's analysis of milk in a 
thousand parts as follows: — 

Water 874.2 

Solids 125.8 

Fat 36.5 

Sugar 48.1 

Salt 7.1 

Proteid (casein, 28.8; albumin, 5.3) 34.1 

Prof. A. Baginsky 28 gives the following analysis of 
cows' milk, made at the Kaiser and Kaiserin Friedrich 
Hospital, Berlin: — 

Water 87.60 

Solids 12.38 

In one hundred parts. 

The solids consist of: — 

Casein and albumin 3.65 

Butter 3.11 

Milk-sugar 4.54 

Inorganic salts 1.08 

Besides large amounts of potassium and potassium 
salts and small quantities of iron. 

COMPOSITION, VAEIATION, AND PEODUCTION. 

Milk of all animals, roughly speaking, is composed 
of the same ingredients, but an analysis of milk is apt 
to be very misleading, as it does not show the physical 



27 "Physiological Chemistry." 

28 "Diseases of Children," 1899, page 32. 



(107) 



108 



INFANT-FHKDINf!. 



condition of the milk, which is the important tiling to 
know from the physician's standpoint. 

The general ingredients of milk are fat, sugar, albu- 
min, casein, mucin, salts, and water. These ingredients 
vary greatly in quantity from day to day and from milk- 




Fig. 21. 



-Cows' Milk, showing Fat-globules. Magnified 
330 Diameters. 



ing to milking. An average analysis of woman's milk 
does not show what an infant is getting, by any means, 
for the composition of the milk depends on the food and 
health of the mother and the frequency of nursing. 

It seems to be pretty well settled that the fat in 
woman's milk usually varies between 3 and 5 per cent., 
the sugar between 4 and 8 per cent., proteids (albumin 



COWS' MILK. 109 

and casein) between 1 and 2 per cent., and the ash be- 
tween 0.2 and 0.4 per cent., the water being about 88 
per cent. Wide extremes are met with; so it is useless 
to think of woman's milk as of a certain composition. 

Cows' milk, which is the only milk worth consider- 
ing in connection with artificial infant-feeding, shows 
great variation in composition, just as does woman's milk. 
There is no such thing as average cows' milk. It may 
be that the mixed milk of a particular herd of cows will 
run uniform in composition for a long time, but this is 
because the variations in the milk of individual cows 
offset each other. A difference of 25 per cent, in the 
amount of fat in night and morning milk has been no- 
ticed in the milk of some cows. This is why "one cow's 
milk" should not be used. Mixed milk of different herds 
of cows will vary between 3 and 5 per cent, fat, 4 and 
5 per cent, sugar, 3 and 4 1 / 2 per cent, casein and albu- 
min, while the ash runs about 0.7 per cent, and the water 
about 88 per cent., all depending on the breed of cows 
and their food. Some breeds give large quantities of 
milk poor in solids, while others give smaller quantities 
of milk rich in solids. 

As a general rule, the shorter the interval between 
milkings, the richer the milk is in solids. Dry food in- 
creases, and succulent decreases the quantity of solids in 
the milk. Slight febrile conditions increase the quantity 
of fat and albumin; depression reduces fat and albumin. 
Casein, sugar, and ash are the least variable ingredients. 

The composition of the fat of milk and the size of 
the fat-globules vary with the period of lactation, the 
breed of cows, and the kind of food used. Linseedmeal 
is said to make a soft, oily fat, while cottonseedmeal and 
some other foods make a hard fat. Small, hard fat-glob- 
ules are noticeable when the animal becomes pregnant. 

The practical problem before the physician in bottle- 
feeding is to prepare a food that approximates mothers' 
milk in composition and physical properties. To get good 



110 INFANT-FEEDING. 

results good cows' milk must be used, and the physician 
should know that this can be had anywhere if strict clean- 
liness is observed by the milkman. 

Aside from the difference in composition between 
cows' milk and woman's milk, cows' milk often contains 
lactic acid and other products of bacterial growth, which 
may cause digestive disturbance. The lactic acid is the 
result of the growth of the lactic bacteria that are always 
found in milk and which get into the milk from the dirt 
in the stable. 

Good milk can be had by keeping the cows clean and 
wiping the udders with a damp cloth just before milking. 
The first three or four jets from each teat should be 
thrown away, as they are always infected, and then the 
milking should be continued into a clean pail. The milk 
should then be immediately cooled to below 45° F., at 
which temperature there is little or no growth of bac- 
teria. Unless this is done the bacteria that always get 
into the milk, no matter how much care is exercised, will 
grow rapidly, and, after they have had a start, all the 
care possible will not repair the damage. Milk produced 
as described has been known to keep in good condition 
in summer in a refrigerator for three weeks and it is not 
at all unusual to buy bottled milk in New York that is 
forty-eight hours old that will not redden litmus-paper. 

Cows' Food. — The natural food, fresh grass, is the 
best; next to this hay is the best. The greater the pro- 
portion of nitrogen in the food, the greater is the yield 
of milk, the proportion of fat being especially high. 
Feeding cows with brewers' grain depreciates the quality 
by lowering the total solids of the milk. Such feeding 
is illegal in a great many States, particularly Wisconsin. 
Beets, carrots, and swedes increase the proportion of milk- 
sugar. 

Average Percentage of Fat. — The average percentage 
of fat found is 4 per cent. The Health Department does 
not condemn milk having more than 3 per cent, of fat. 



TUBERCULIN REACTION IN COWS. Ill 

The uniformity of milk, particularly in Xew York City, 
is certainly due to the extreme care and vigilance of the 
Board of Health of our city. It is not surprising that 
milk is so frequently adulterated when it is possible to 
add about 20 per cent, of water or 30 per cent, of skim- 
milk to milk of average quality without the resulting 
mixture falling below the present requirements. 

Tuberculin Reaction in Cows. 

Conclusions as to the tuberculin test, in the Bulletin 
of the Massachusetts Agricultural College: — 

1. Tuberculin furnishes a very delicate and reliable 
test, and is the only means by which tuberculosis can be 
stamped out. 

2. A certain number of sound cows will show the 
tuberculin reaction. 

3. A certain number of tuberculous cows will not 
show the tuberculin reaction. 

The Cattle Commissioners of Massachusetts had, at 
Brighton, on February 15, 1895, 40 cattle which they 
had subjected to the tuberculin test and condemned as 
tuberculous. The figures of the tuberculin test were 
carefully reviewed at the office of the commission in 
Dorchester, and it was decided that 13 of the lot should 
be killed on that day. 

There were present Commissioner Herrick and Dr. 
Lyman, secretary of the commission; Dr. Burr, inspector 
for the city of Boston; and Dr. Way, acting in behalf 
of the owners. 

At the last moment it was discovered that 3 of the 
cows had not been appraised and 10 only were killed. 

Two of the 10 were undoubtedly tuberculous. Four 
were pronounced to be so by Commissioner Herrick and 
Dr. Lyman, but declared not to be so by Dr. Way. Their 
organs were, therefore, sent to Professor Whitney, of 
Harvard College, for microscopical examination. In 1 of 
these 4 cows an abscess was found in which was a short 



112 INFANT-FEEDING. 

nail which had apparently caused it. By the most care- 
ful examination the commissioners could find no signs 
of tuberculosis in the 4 remaining cows, and they were 
accordingly dressed and sold for beef. 29 

Causes of Tuberculous Diseases in Children. 

Dr. J. Walter Carr 30 has made investigations as to 
the starting-point of tuberculous disease in children; he 
made post-mortem examinations in 120 cases of children 
who died at the Victoria Hospital, Chelsea, Eng., of vari- 
ous forms of tuberculosis. He concluded that in two- 
thirds of the cases the disease began in the thorax and 
evidently was not due to tuberculous milk (that is, in- 
fection from the food) and that milk is by no means a 
frequent channel of infection as compared with infection 
by the lungs. It is often asserted that tuberculous milk 
causes the greater part of deaths in children; even sum- 
mer diarrhoea, cerebral meningitis, peritonitis, "consump- 
tion of the bowels," etc., are laid to the door of tubercu- 
lous cows. The fallacy is that consumption (tuberculosis) 
in children is a generalized condition; in the adult, a 
localized condition. The mesenteric glands are often 
affected in children, but careful examination shows that 
the starting-place was in the thorax. The point is, not 
what organs are affected at death, but in what organ 
the disease begins. Dr. Carr says that bacilli are omni- 
present, and it is impossible to keep a child from contact 
with them. The great points in the prevention of tuber- 
culosis in children are the maintaining of perfect health 
and avoiding respiratory and gastro-intestinal catarrh, and 
keeping the mucous membrane healthy. 

Yellowish Milk. 
Before and after calving milk is yellowish, due to 
the presence of small, yellow bodies. Such milk is called 



29 Spy, Worcester, Mass. 

30 Lancet, May 12, 1894. 



FROZEN AXD SOUR MILK. 113 

colostrum, and in the case of cows is unfit for human 
consumption. 

Pus-cells rather larger than the red blood-corpuscles, 
granulated, and with a core or irregular contour, are 
found, as are blood-corpuscles, in the milk of sick cows. 
They are prevented, as Soxhlet has pointed out, from 
coalescing into an oily film by the condition of the albu- 
min, which isolates the fat-corpuscles in its meshes. 

Frozen Milk. 

Partial freezing of milk produces a concentration of 
the solids in the part remaining liquid, while the part 
frozen is deficient in them. In winter, when milk has 
undergone a partial freezing, great care should be taken 
to allow it to thaw and then to thoroughly mix the same 
before allowing it to be sold. 

Sour Milk. 

When milk stands for some time, fermentative changes 
due to a micro-organism — usually bacillus acidi lactici — 
take place. This decomposes the milk-sugar, resulting in 
the production of lactic acid, which eventually causes the 
milk to become sour. The change is very largely depend- 
ent upon the time the milk has been allowed to stand, and 
more particularly upon the temperature of the place in 
which it is kept. 

When the fermentative change has resulted in the 
production of about 0.4 per cent, of lactic acid, the milk 
can be distinctly recognized, by the taste, to be sour. 
AVhen the acidity reaches 0.6 per cent, the milk curdles, 
and it spontaneously separates into a solid, known as curd, 
which consists of the fatty and proteid constituents of the 
milk, and a clear liquid known as whey, which consists 
essentially of a solution of milk-sugar and mineral salts. 
This same change is brought about artificially when we 
add rennet. 



114 infant-feeding. 

Koumiss. 

This is a preparation of mares' or asses' milk in a 
partly fermented condition, largely used in Russia. It is 
prepared as follows: The milk is allowed to cool, and is 
then deprived of a part of its cream; a little yeast is then 
added. This sets up a slow fermentation, the milk-sugar 
being converted into alcohol and lactic acid. During the 
fermentation the milk is subjected to frequent agitation, 
the object of which is to maintain in suspension the 
casein, which has a tendency to separate during the fer- 
mentation. Koumiss (called Kumyss) is prepared in this 
country from cows' milk. The chief manufacturer is Dr. 
E. P. Brush, of Mt. Yernon, X. Y. Another preparation 
which I have used is known as zoolak and is made by 
Dr. Dadirrian. 

Giaouedi. 

Giaourdi, a food similar to junket and very highly 
nutritious, has been introduced by Dr. A. Rose, of Xew 
York City. It is largely used in Greece, and is adapted 
for subnormal digestion. The author some time ago used 
this food and noted aood results in a child suffering: with 
marked leucocytosis following pneumonia. It is also 
adapted for the convalescent period, when restorative 
foods are indicated. 



CHAPTEK XVII. 

Buttermilk Feeding. 

A very elaborate paper on the subject of buttermilk 
feeding, by Dr. Teixeira de Mattos, of Rotterdam, lias re- 
cently appeared. 31 He cites de Jager, who published a 
paper 32 recommending this form of feeding; Karger 33 ; 
Houwing 34 ; and private and public reports of Schloss- 
mann, Heubner, Soltmann, Finkelstein, de Mattos, and 
others. 

While practically unknown one year ago, it is now 
pushing its way forward. In Holland this treatment is 
very popular. 

Buttermilk feeding of children is by no means new, 
having been used in 1790 by P. Campert (cited by 
Biedert). Very little appears in literature about this 
article of diet until in 1865 Dr. Ballot, of Holland, 
again revived and recommended it. 

To Prepare the Food: Take 1 quart (liter) of buttermilk; 
add 1 even tablespoon fill of rice, wheat, or other flour desired 
(about 10 to 12 grammes) ; heat the mixture over a small gas 
fire, with constant stirring, until it has boiled up three different 
times (requiring about twenty-five minutes) ; then add 2 or 3 
tablespoonfuls (about 70 to 90 grammes) of cane-sugar or beet- 
sugar. It is better to use new enameled ware or agate ware 
for preparing this food. The food as above prepared assumes 
a yellowish color. 

31 Jalirbucli fiir Kinderheilkunde, January, 1902. 

32 Nederlandsch Tydschrif t voor Geneeskundigebladen, October, 
1895. 

33 "Die Verdauimg und assimilation des Gesunden und Kranken 
Sauglings, nebst einer rationellen methode zur Senglingsernahrung," 
Berlin, 1898. 

34 Centralblatt fiir Gyniikologie, 51, 190. 

(115) 



116 INFANT-FEEDING. 

It is necessary to have large corks for the bottle or the 
food coagulates and gets lumpy, in which event it would re- 
quire occasional shaking to bring the thickened portion to 
the proper consistency. 

De Mattos reports a series of cases in which butter- 
milk was used. The bulk of these cases were anaemic, 
atrophic cases requiring restorative treatment. In all 
cases reported the weight was increased and dyspeptic 
symptoms, when present, rapidly disappeared. 

The increase in weight noted by de Mattos was from 
500 to 700 grammes weekly in debilitated children, and 
Schlossmann reports as much as 700 grammes' increase 
in six days. 

Graanboom, in his recent book on "Diseases of the 
Digestive Tract in Children" (1901), states that he also 
is very much impressed with the value of buttermilk as 
an infant-food. 

De Mattos states that children so fed for a period of 
six to eight months show signs of rickets or late dentition, 
although they look well and appear to be well nourished. 
Whether or not other methods are worse he does not state. 

Lactic acid was never found in the urine of infants 
fed either with lactic acid or its salts. This series of 
experiments was made by de Mattos, and the results were 
corroborated by Houwing. 

The amount of lactic acid present in buttermilk has 

been carefully studied. Robertson, a chemist, found it 

to be: — 

Minimum 0.09 per cent. 

Maximum 0.45 per cent. 

De Jager believes that good buttermilk does not con- 
tain more than 0.5 per cent, of free lactic acid. 35 These 
are, however, not absolute and positive data, but really 
individual hypotheses. 



35 Nederlandsch Tydschrift voor Geneeskundigebladen, 1899, i, 
S. 945. 



BUTTERMILK-FEEDING. 117 

Contrary to the ideas of Munk, Ufielmann, and Ewald 
(who fear the use of food containing lactic acid), de Mat- 
tos has found that chronic enteritis and gastric complaints 
soon improve when an exclusive buttermilk feeding is 
resorted to. Hayem and Lesage regard lactic acid as en- 
tirely innocuous for nurslings. According to the above- 
named investigators, lactic acid is not toxic for infants. 
They gave experimentally 15 to 20 grains in divided 
doses, mixed with sugar, without seeing any detrimental 
results. Jaworski 36 found no trace of lactic acid in an 
infant's stomach one hour after administering it. 

Kiel maintains that lactic acid improves digestion, 
while Duclaux 37 states that lactic acid is a valuable as- 
tringent. Heubner 38 found lactic acid in the stomach 
of two healthy infants (to the extent of 0.16 to 0.2 per 
cent.). Marfan (quoting Zotow) maintains that, when 
lactic acid is found in the stomach of infants, it is always 
a pathological factor. 

Buttermilk in its crude (raw) state is certainly an- 
tagonistic to other micro-organisms. This is due to the 
presence of lactic-acid bacilli. Raw cows' milk possesses 
bactericidal properties, but buttermilk is much more bac- 
tericidal. The latter, sterilized with the aid of steam, 
showed virulent typhoid bacilli nine days after being in- 
oculated with the same. In non-sterilized buttermilk 
{raw state) virulent typhoid bacilli lost their virulence 
after two days, and when put into the brooding oven lost 
their virulence after twenty-four hours. The bacillus 
lacticus of Pasteur and Hueppe seems to be identical with 
the bacillus lactis aerogenes of Escherich, 39 which is found 
in the upper part of. the small intestine. 

Jaworski found that pepsin is more readily secreted 
when lactic acid is given internally. De Mattos states 

36 Deutsches Arehiv fur klinische Medicin, Bd. xxxvii, i. 

37 "Maladies de l'Enfance," tome ii, p. 606. 

38 "Jahrbuch fur Kinderheilkunde," 1891. 

89 "Die Darmbaeterien des Sauglings," Stuttgart, 1886. 



118 INFANT-FEEDING. 

that he has never met with a case of Barlow's disease 
among infants fed with buttermilk. 

Disagreeable symptoms are frequently encountered 
for the first few weeks while giving buttermilk. Such, 
are frequent vomiting and diarrhoea. These are not 
contra-indications for feeding, and, notwithstanding the 
presence of the above-named symptoms, the feeding should 
be continued. If, however, the symptoms are very severe, 
then the administration of astringents — such as bismuth, 
argent nitrate, tannalbin, or ichthalbin — may be required 
for temporary relief. 

An important point is that in this form of infant- 
feeding the large, thick, cheesy curds so commonly met 
with in dyspepsia and diarrhoeas in feeding with cows' 
milk are never seen. Children thus fed seem to with- 
stand the infectious diseases very well. A point worth 
noting, is that when a child is more accustomed to butter- 
milk feeding the change to sweet milk will cause diar- 
rhoea. 

When we find that the weight is not increased and 
we desire to change to sweet milk, the latter should be 
gradually added to the buttermilk instead of making a 
distinct change suddenly. 

Quality of the Buttermilk. — This is the most impor- 
tant part of our subject. In securing our food we must 
be sure that we are dealing with honest dairymen whose 
sole object is to deliver what is demanded for weak in- 
fants. Stale combinations made by the use of left-over 
centrifuged milk or skim-milk or spoiled milk which 
cannot be used otherwise should be inquired into and 
rejected. 

Good buttermilk can be made from either whole milk 
or from cream. In Holland buttermilk is made by pas- 
teurizing cream in Timpe's apparatus and then inoculat- 
ing and buttering the same with a pure culture of lactic- 
acid bacillus. In order that raw milk will vield butter- 
milk a certain percentage of acidity must be present. 



BUTTERMILK-FEEDING. 



119 



The usual precautions in milking (so-called modern 
stable hygiene) must be observed in securing milk to be 
nsed in making buttermilk. The milk should be received 
in sterile vessels and rapidly cooled, and should then be 
kept in cool cellars or ice-coolers having a low tempera- 
ture (no higher than 15° or 20° C.) for eighteen to 
twenty-four hours. It is necessary to stir the milk occa- 
sionally. Rapidity of souring can be assisted by adding 
sour milk or by inoculating with a pure culture of lactic- 
acid bacilli. rTo definite rule can be laid down as to when 
buttering takes place; empiric methods must decide this 
matter. This is due to the size of the vessel used and 
the influence of seasonal changes, and also the amount 
of churning it had received. Cows' milk which contains 
colostrum or which is bitter is not adapted for buttering. 

Butter should form in small, pin-head-sized particles 
in thirty to forty-five minutes. It is regarded as a mis- 
take to have large particles of the size of a pea or larger, 
and dairymen look upon such buttermilk with suspicion. 
Buttermilk in general contains about 0.3 to 0.4 per cent, 
of fat. 

Escherich states that the fermentation of milk is due 
to the splitting up of the milk-sugar whereby lactic acid, 
O, and C0 2 are formed in the intestine. 

The following table is instructive in showing the per- 
centage of acidity present and also the difference in fat : — 





Specific 
Gravity. 


Solids, 
Percentage. 


^ ! Acidity According 
Fat 

to Soxhlet-Hexkel. 


Sour milk before 
buttering 


1.029 


11.40 


2.8 


18.1 


Buttermilk 


1.029 


9. GO 


0.5 


16.1 



There is, therefore, a difference of 2 per cent, in the 
amount of acidity present in favor of buttermilk. 



120 INFANT-FEEDING. 

An important point is to overcome the lumps usually 
found as coarse coagula in buttermilk. Be Mattos advises 
adding flour — either rice, wheat, or lentil — or even some pro- 
prietary infant-foods, according to the requirements of the 
infant. 

This is merely given to hold the nocculi in finer form 
and to prevent their coagulation into lumps. Dyspeptic 
children with subnormal digestive powers should receive 
a minimal quantity; thus, an even tablespoonful, amount- 
ing to about 10 grammes, will suffice. 

Addition of Sugar. — The quantity of sugar to be 
added must be reckoned empirically; thus, 3 tablespoon- 
fuls, about 90 grammes, are required to each liter of 
buttermilk. Rarely do we need more than 100 grammes. 

Cane-sugar or beet-sugar serves best for sweetening. 
Sugar cannot be found in the urine nor in the fasces of 
infants fed on buttermilk to which sugar was added. 

The results which might be expected from using cane- 
sugar — such as diarrhoea, fermentation, sour eructations 
■ — are totally absent in using buttermilk feeding. 

Stools. ■ — The average buttermilk-fed infant has no 
more than one or two stools daily. They are more or 
less solid in consistency and have an alhaline reaction. 
It would be incorrect to state that all children fed with 
buttermilk must have yellow stools. We know that even 
Uffelmann, in his studies of infant-stools, states that 
breast-fed infants show great variations from apparent 
normal stools and still thrive. "We also know that bottle- 
fed infants reared on cows' milk have no definite hind 
of stool which we could call a standard stool. Still, the 
buttermilk-fed infant never has the coarse casein particles 
in the fasces that we see very frequently in the stools of 
infants fed on cows' milk. 

The bacteriological examination of the faeces made 
by inoculating gelatin plates with diluted fasces showed: — 

1. Liquefying colonies rendered Loeffier's nutrient 
gelatin strongly alkaline. Inoculated into bouillon, the 



BUTTERMILK-FEEDIXG. 121 

latter remained clear, forming a skim on the surface. 
Milk was not coagulated by these micro-organisms. They 
formed spores, generated H 2 S, and can therefore be iden- 
tified as the bacillus butyricus of Hueppe. 

2. Xon-liquefying colonies were inoculated into milk- 
sugar bouillon and left in the brooding oven eight hours 
at 37 °C. All tubes so treated were turbid on standing 
over night; this fact excludes the possibility of its being 
the bacterium coli. 

Other properties were found, such as: fermentation 
in milk-sugar bouillon, no skim forming on the bouillon; 
indol does not form in peptone solution (bacterium coli 
would form indol); milk turns sour but slowly; no ]STH 3 
formation. 

From a study of the above properties we conclude: — ■ 

1. Bacterium coli commune must be excluded. 

2. Bacterium coli lactici, Hueppe (resp. bacterium 
lactis aerogenes, Escherich), must be identified. 

The lactic-acid bacillus, found in boiled as well as 
raw buttermilk, loses its potency in the intestinal canal 
in the presence of the bacillus butyricus, Hueppe. The 
latter germ grows in overwhelming numbers and renders 
the intestinal contents rapidly alkaline. 

An interesting point is that, if the buttermilk were 
originally very sour, the feces will be very alkaline, show- 
ing how weak the bacterium acidi lactici is. 

Feeding. — The writer has seen excellent results from 
buttermilk feeding in atrophic and marasmic children. 
As an article of diet during convalescence after pneu- 
monia and typhoid fever the results were encouraging. 

Quantity to he Fed. — Buttermilk as above prepared 
should be fed exactly as would other milk. Four ounces, 
increased to 5 or 6 ounces, can be fed every 3 hours, or 
the interval may be prolonged to 3 1 / 2 or 4 hours. It 
will be necessary to coax the child in beginning with this 
new form of feeding, owing to the difference in the taste 
of fresh milk and buttermilk. 



CHAPTER XVIII. 

Detection and Addition of Preservatives to Milk. 

The preservatives most frequently employed are: 
borax and boric acid, formaldehyde, salicylic acid, and 
potassium chromate. 

Formaldehyde 40 is the most effective, and, when the 
same becomes better known, it will supersede all other 
preservatives. The above chemicals are sold to farmers 
and dairymen as "milk-preservatives." The table on the 
following page will show the efficiency of the various 
milk-preservers, and is taken from T. H. Pearmain and 
C. G. Moor, on "Milk and Milk-products." 

Formaldehyde is usually added to milk in the form 
of a 40-per-cent. solution, commonly called formalin; 2 
or 3 drops added to a pint of milk will keep it fresh for 
three or four days, and the addition of 0.05 per cent, 
will preserve milk for months. In the trade a much more 
dilute solution is generally employed, namely: 1 part of 
formaldehyde to 80 parts of water. Rideal states that a 
quarter of a pint of such a solution will keep seventeen 
or eighteen gallons of milk fresh for at least three days, 
and will not impart any smell or taste to the same. On 
tasting milk containing formaldehyde a peculiar sensa- 
tion is noticed at the back of the throat, and when strong 
hydrochloric acid is added to it (Werner Schmidt process) 
the casein turns yellow and is less soluble than that of 
pure milk. Hehner's test is the most reliable. When 



40 The New York Medical Record, as recently as July 21, 1900, 
contains the following: — 

"Many milk-dealers in New Jersey have been arrested on the 
complaint of the State dairy commissioner for adulterating milk, 
the special adulterant being formaldehyde, added as a preservative." 

(122) 



DETECTION AND ADDITION OF PRESERVATIVES. 



123 



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Per Cent. 


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124 INFANT-FEEDING. 

milk, formalin, and sulphuric acid are mixed together a 
blue coloration is formed. According to Richmond and 
Bosely, it is best to dilute the milk with equal quantities 
of water and add sulphuric acid, about 90- to 94-per-cent. 
strength. When formalin is absent, the milk gives a 
slight-greenish tinge at the junction of the two liquids, 
while a violet ring is formed when formaldehyde is pres- 
ent. This color remains permanent for several days. In 
the absence of formalin, a brownish-red color is developed 
after some hours, not at the junction of the two liquids, 
but lower down in the acid. This cannot be mistaken 
by anyone who has had any experience with the test for 
the formaldehyde reaction. It is stated that 1 part of 
formalin can be easily detected by means of this test in 
200,000 parts of milk, but the blue coloration is not ob- 
tained with milk containing over 0.5 per cent. 

Another very sensitive test for the detection of for- 
malin in cows 7 milk is the following: If to the distillate 
from a sample of milk 1 drop of a dilute aqueous solution 
of phenol is added and the mixture poured upon strong 
sulphuric acid contained in a test-tube, a bright-crimson 
color appears in the zone of contact. This color is still 
readily seen with 1 part of formaldehyde in 200,000 of 
water. If there is more than 1 part in 100,000 there 
is seen above the red ring a white, milky zone, while in 
stronger solutions a copious white or slightly pink, curdy 
precipitate is obtained. This reaction has an advantage 
over the one previously referred to, as it is obtained with 
formaldehyde solutions of all strengths, while the blue 
color of milk is not obtained with milk containing much 
formaldehyde. 

Salicylic acid is not very much in vogue as a milk- 
preservative. It can easily be detected by Pellet's method : 
200 cubic centimetres of the milk are diluted with an 
equal measure of water, heated to 60° C. and treated with 
1 cubic centimetre of acetic acid and an excess of mer- 
curic nitrate free from mercurous salt. The salicylic acid 



DETECTION" AXD ADDITIOX OF PRESERVATIVES. 125 

is extracted from the filtered solution by agitation in ether 
and recognized by evaporating a little of the ethereal 
solution to dryness and testing the residue with ferric 
chloride, which gives a violet color with salicylic acid. 

Pearmain and Moor, in describing the bacteriology of 
milk, say that it usually contains a large number of bac- 
teria derived from the external surroundings of the cow. 
Where these are unclean, the number may reach three or 
more millions per cubic centimetre. These can, "for ex- 
perimental purposes," be completely separated by filtra- 
tion through Pasteur tubes, the tubes being cleaned at 
short intervals. A thin, watery serum constitutes the 
filtrate, the whole of the fat being arrested with the 
organisms, so that milk cannot therefore be freed from 
organisms for practical purposes by any known system 
of filtration. Milk can be curdled by ferments even in 
the absence of an acid reaction. The most notable fer- 
ment is rennet, obtained from the stomach of a calf. 
Hueppe first pointed out that such ferments are conveyed 
by many different bacteria which precipitate the casein 
in the presence of a weakly acid, amphoteric, or even 
neutral solution. The numerous tyrothrix bacilli isolated 
by Duclaux, the bacillus pyocyaneus, yellow sarcina, and 
particularly the organisms described by Pliigge, 41 char- 
acterized by their capacity to peptonize milk, belong to 
this class. Cohn 42 produced the precipitation even by 
means of bacteria, whose vegetative capacity had been 
completely abolished wdth chloroform, thus showing that 
the fermentative action was due to a substance independ- 
ent of the metabolic products of the organism. These 
substances have been isolated by Cohn and others. They 
are destroyed in most cases at from 65° to 75° C. Some 
ferments, however, as, for example, that described by 
Gorini in association with the bacillus prodigiosus, resist 



41 Zeitsehrift fiir Hygiene, xvii, page 272. 

42 Centralblatt fiir Bacteriologie, ix, page 653. 



126 INFANT-FEEDING. 

as much as an hour's exposure to 70° or 80° C, and 
require at least half an hour's exposure to 100° C. (or 
212° F.) for their destruction. 

It is practically inevitable that milk, as delivered 
from the cow, should contain a number, and usually a 
very large number, of bacteria. The extent of their 
presence is, however, affected by many circumstances, of 
which some are also indications of unwholesomeness or 
danger. Many of the organisms which are capable of 
causing disease do so by producing toxic decomposition- 
products from the milk. Their vegetative capacity in- 
creases greatly with rise of temperature, and it is there- 
fore an essential condition of sanitary milk-production, 
and especially of a milk designated as suitable for children, 
that it should be kept at a low temperature during the 
whole of the interval between being drawn and being con- 
sumed. 

Yellow milk is said to be colored by the bacillus syn- 
xanthus of Schroter, the color being removed by acids and 
restored by alkalies. 

Salty milk is stated to occur only in connection with 
inflammation of the udder. It is to be detected not only 
by its taste and its high percentage of ash, but by its low 
percentage of milk-sugar. Its specific gravity is 1.027 
to 1.029. According to Klenze, 2.4 per cent, of small 
deposits of calcium carbonate in the milk-glands may give 
rise to sandy milk. Curious results have been noted by 
Scheurlen 43 in experimenting with bacteria in milk. He 
found that milk can be freed from bacteria by the opera- 
tion of a centrifugal machine. He also noted that, of the 
large majority of bacteria contained in milk, three-fourths 
went into the cream on being centrifugalized, and the 
rest stayed in the separated milk, and the same result was 
obtained by merely leaving the milk stand. These results 
held good not only for the ordinary milk bacteria, but also 



* 3 Arbeiten a. d. k. Ges. Amt., vii, 1891. 



THE BREED OF A COW. 127 

for anthrax, typhoid, and cholera. The tubercle bacillus 
only remained to a small extent in either the milk or the 
cream, and the large majority was ejected under the cen- 
trifugal influence. The biological commission on milk- 
supply held under the auspices of the British Medical 
Journal for 1895, reported the following: 1. That all 
milking be carried on in the open air, the animal and 
operators standing on a material which is capable of being 
thoroughly w T ashed, such as a floor of concrete or cement. 
Such a floor could be easily laid down in any convenient 
place which can be found. The site chosen should be re- 
moved from inhabited parts as far as possible, and should 
be provided with a plentiful water-supply. Only in this 
way does it seem possible to avoid the initial contamina- 
tion with the colon bacillus. 2. That greater care should 
be expended on the personal cleanliness of the cows; the 
only too familiar picture of the animal's hindquarters, 
flanks, and side being thickly plastered with mud and 
fasces is one that should occur no longer. It would not 
be difficult to carry out this change. Indeed, in the better 
managed of our large dairy companies' farms such a con- 
dition no longer prevails, but in the smaller farms it is 
but too frequently met with. 3. That- the hands of the 
milker be thoroughly washed before the operation of 
milking is commenced, and that after once being washed 
they be not again employed in handling the cow, other- 
wise than in the necessary operation of milking. Any 
such handling should be succeeded by another washing in 
fresh water before again commencing to milk. 4. That 
all milk-venders' shops should be kept far cleaner than 
is often the case at present; that all milk-retailing shops 
should be compelled to provide proper storage accommo- 
dation, and that the counters, etc., should be tiled. 

The Breed of a Cow. 

Some breeds yield quantity, others quality. Holsteins 
produce the most milk; Alderneys and Jerseys yield the 



128 INFANT-FEEDING. 

most fat; shorthorns give the most casein and sugar. The 
average capacity of a cows' udder is about 5 pints, and 
the annual yield of milk is about 600 gallons. 

Time and Stage of Milking. 

Cows are usually milked twice a day, the morning 
milk usually being larger in quantity and poorer in qual- 
ity. The milk which is first drawn is known as the fore- 
milk, and contains very much less fat than that last drawn, 
known as the stoppings. This is due to a partial cream- 
ing taking place in the udders. Dishonest dealers have 
often taken advantage of this fact in adulteration cases to 
have the cows partially milked in the presence of ignorant 
witnesses, the resulting milk consisting largely of the fore- 
milk. 

Age of Cows. 

Young cows give less milk, while cows from four to 
seven years old give the richest milk, and less milk is 
given with the first calf. They give the largest yield, ac- 
cording to Fleishmann, after the fifth until the seventh 
calf; after the fourteenth calf they yield, as a rule, no 
more milk. The poorest rnilk is yielded during the spring 
and early summer; the richest during the autumn and 
early winter. If cows are worried or driven about, the 
quality and quantity of the milk are reduced. If they 
are kept warm and well fed, both quantity and quality 
are naturally increased. 

Effect of Alkalies on Milk. 

By running milk through a centrifugal machine a 
product known as "separator slime" is produced, which is 
analogous to mucin. A decided difference in viscosity is 
noticed between milk before and after running it through 
a centrifugal machine. This "separator slime" swells up 
and forms a viscid jelly with lime-water or alkalies. Milk 
to which alkali is added is decidedly more viscous than 



ALBUMINOIDS IN COWS' MILK. 129 

milk that is slightly acid, and is so undoubtedly because 
of the action of the alkali on the mucin of the milk. 

Curdling of Milk and Diluents. 

Milk of all animals may be separated into two classes. 
Those that form a soft curd with rennet and those that 
form a hard curd with rennet. Woman's milk is in the 
first class and cows' milk in the second. 

The conditions favorable for the formation of hard 
curds of cows' milk are body-heat and the presence of 
rennet and lactic or other acid. 

The rennet forms a clot of the milk, the heat causes 
the lactic bacteria to grow in the curd, and the acid causes 
the curd to shrink and become leathery. Adding alkalies 
to the milk neutralizes the acid, but the bacteria will keep 
making more lactic acid as long as any sugar is present. 

Diluting milk with water does not prevent tough 
curds forming, but diluting with gruels does prevent the 
contraction of the curds. This has been proved beyond 
dispute, both experimentally and clinically. 

Albuminoids in Cows' Milk. 

That there are differences in the amounts of the albu- 
minoids occurring in human milk is proved by the fact 
that, while Professor Leeds found a variation of 0.85 to 
4.86, Professor Meiggs asserts that there was but 1 per 
cent. 

Konig, an earlier analyst, makes the variation from 
0.85 to 4.86. Some of these results give as high a per- 
centage of albuminoids in woman's milk as we find in 
cows' milk, and I have no doubt in my own mind that 
the time and habit of extracting the milk has a deal to 
do with the amount of occurring albuminoids. In other 
words, when milk is extracted every two hours or less, it 
cannot contain as much of the cell-material as milk from 
the same source extracted at intervals of twelve hours. 
This latter is riper and it is the non-uniformity of the 



130 INFANT-FEEDING. 

tissue which causes all the difference in the different oc- 
curring albuminoids. We know that during the incuba- 
tion of eggs casein is developed from egg-albumin. This 
illustrates the ripening of albumin. Furthermore, take 
an egg just laid by the hen, and boil it, and you will find 
immature albumin in it; that is, after boiling, instead of 
being thick and firm, like an older egg, much of it is 
milky. If boiled a few hours later, all the albumin will 
coagulate perfectly, because it has had time to ripen. 
There is no doubt that the albuminoids in milk from 
healthy animals are all cell-transformations, not an exu- 
date, as are undoubtedly the fats and salts, because these 
latter we can influence by the food very plainly, but in 
health the albuminoids are constant without regard to 
food, while during menstruation, pregnancy, and other 
conditions, notably febrile disturbances, we find the fats 
and salts not materially affected, but the albuminoids de- 
creased, increased, or totally changed, as in the case of 
colostrum. The casein, besides being riper in cows' milk, 
by reason of its stronger growth, is intended by Xature 
to coagulate into a hard mass, because it is the product 
of a cud-cheAver for the nourishment of a cud-chewer, 
and the reason why it does not alwavs coagulate in the 
infant's stomach as it does in that of the calf is that the 
latter animal's stomach secretes a principle called cliy- 
mosin; this is the principle that curdles cows' milk, and 
it operates either in an acid or an alkaline medium. Pep- 
sin will not coagulate milk, and hence the hard coagulum 
of cows' milk that sometimes forms in the infant's stom- 
ach is due to acidity of that organ, and this acidity is not 
always the fault of the stomach, but of the milk itself. 
The variations in the chemistry of the albuminoids found 
in cows' milk would not be surprising to anyone if he 
would examine into the condition of some of its mam- 
mary sources. Thus it will often be found, on dissecting 
a cow's udder, which I always do when making an au- 
topsy on a cow, that there are old cicatrices, one or more 



ALBUMINOIDS IX COWS J MILK. 131 

quarters of the udder intensely inflamed, sometimes a 
mammiferous duct clogged with a calculus or a clot of 
fibrin. Besides these pathological conditions, the mam- 
mary gland is subject to benign and malign infiltrations, 
bacillary tubercular deposits, and eruptive diseases of the 
skin involving the gland and ducts. Therefore, that 
fibrin, serum, and albumin, in various forms, are found 
in the cows' milk is not surprising, and it can safely be 
assumed that any variation in the albuminoids from the 
normal casein can be ascribed to sickness on the part of 
the animal. 

"We next come to the salts contained in milk, and it 
is remarkable how few analyses have been made to deter- 
mine the salts or minerals that are contained in this fluid. 
Heidlen's analysis, copied everywhere, seems to be the 
only exhaustive one of the salines in cows' milk made 
during the past century. It seems to me in this case, 
too, that it is time for the chemist to teach us something 
more. There probably never was a time, in our era, at 
least, when milk was attracting so much attention as now, 
and still all our chemists are content with the total solids, 
fats, albuminoids and sugar — just what the butter-makers 
and cheese-makers want to know. From this much-quoted 
analysis of cows'-milk salts we learn that milk contains in 
various proportions the phosphates of lime, magnesia, and 
iron; the chlorides of potassium, sodium, and iron; and 
free soda. Robin gets from human milk, in addition to 
the foregoing, carbonate of lime and soda, phosphate of 
soda, sulphate of soda, and potash. We have no means 
of knowing how constant is the occurrence of any of these 
salts in milk or under what conditions they are modified; 
we do know, however, from the experiments of Fehling, 
that many of the drugs administered to the milking fe- 
male are excreted in the milk. Therefore, we can safely 
assume that the saline constituents occurring in milk are 
influenced both by the health and food of the animal. 
That the phosphates are craved for by the milking cow is 



132 INFANT-FEEDING. 

evidenced by the habit of chewing old bones and the like, 
and that there is a lack of this element of food is not to 
be wondered at when we see herds of milking cows 'pas- 
tured on old, worn-out lands; the practical farmer knows 
that exhausted pasture-lands need, more than anything 
else for their rejuvenescence, the phosphates, and we 
know that in our nutrition we need them also. The land 
on which a cow is pastured will indicate pretty fairly 
what we may expect to find in her milk as salts. We 
have all noticed the excessive growth of sorrel on ex- 
hausted land. Can it then be a subject of wonder that 
some kind of a vegetable acid should be found in the milk 
of animals that are obliged to include this variety of food 
in their summer-rations and sour ensilage or spoiled brew- 
ery grains in their winter-feed? Theodore Hankel's dis- 
covery of citric acid in cows' milk to the amount of 0.9 
and 1.1 grammes per litre is just what might be expected. 

Sugar, I think, in milk has always been overestimated 
as to its nutritive value, because we know that carnivo- 
rous animals do not secrete sugar to any appreciable ex- 
tent, according to chemists. When we see a small slut 
nursing seven or eight puppies and keeping them all fat, 
and in a thriving condition, we can easily imagine that 
sugar is not a necessary element of food, for the canines 
excrete no sugar in their milk. We see that the gross re- 
sult of condensed-milk feeding with an excess of sugar is 
harmful. Brush maintains that pure cane-sugar is the 
ideal addition to cows' milk. 

Prof. L. B. Arnold, an authority on dairy matters, 
says that when milk will not properly nourish an infant 
it is not the cows' milk that is at fault, but that it is 
either a pathological condition of the cow or improper 
food or care, or the conditions through which the milk 
has passed on its way from the cow to the infant. 

The average temperature of a cow is 102 1 / 2 ° F. 
(Brush). This is certainly a peculiarity of the cow. An- 
other peculiarity is the constant employment of her gen- 



ALBUMINOIDS IN" COWS'' MILK. 133 

erative functions : she is always milking or pregnant, and 
both the uterus and the mammary glands are employed 
almost constantly at the same time. Her nervous system 
is more subject to severe shocks, and she is a delicate 
creature. As regards the average income from a cow, it 
is about $20.00 a year to the producer. This is about 
7 cents a day, from which the dairyman has to buy food 
and pay for labor. In order to make a profit the dairy- 
man must utilize ei r ery drop of milk, whether the animal 
giving it be sick or well. It is, therefore, very common 
to find that all the cheap foods, such as brewery grains, 
distillery slops, and the refuse from starch-factories enter 
largely into the food from which our babies' supply of 
milk is produced. Brush maintains that personal inspec- 
tions of small dairies near New York City showed the sole 
article of diet to be swill. One of the means employed 
for removing the stable odors of milk is adding nitrate 
of potash, commonly known as "saltpeter." With this 
drug a substance resembling nitroglycerin is formed. It 
is strange that the toxic effects of nitroglycerin are sim- 
ilar to those of tyrotoxicon. 

Brush believes that the ideal dairy for supplying in- 
fant-food should be composed entirely of spayed cows, 
and thus one constant source of nervous function of dis- 
turbance would be eliminated. He believes that these 
animals are much more quiet in disposition, they give a 
more constant and uniform supply of milk, and seem to 
enjoy a more even degree of health than the cow who is 
occasionally bulling and becoming pregnant when giving 
milk. The author has certainly had very good results 
with Brush's milk, and, although it is somewhat expensive, 
he has found it well adapted for the home-modification of 
infants' food. 



CHAPTEE XIX. 



Cream. 



When food contains too little fat, or its equivalent 
(cream), we have fat-starvation, which is soon manifested 
by symptoms of rickets. One of the earliest symptoms of 
rickets is constipation, showing deficient muscular tone: 
a distinct atony of the bowel. 

This can be remedied by the addition of fat or cream 
to the food. Some children are benefited by giving them 
codliver-oil, butter, or olive-oil. Some authors advise giv- 
ing fried bacon to very young children; thus it is plain 
that each one desires to remedy the deficiency of fat in 
his own manner. 

In buying cream from small milk-stores one can make 
a rough guess at the proportion of fat in cream by its 
thickness. A 50-per-cent. cream at the ordinary tem- 
perature of the room runs from a jug slowly and in a 
thick stream, almost like thick mucilage, whereas a 16- 
per-cent. cream runs almost as freely as milk. This is, 
however, a crude way of estimating the difference be- 
tween poor and rich cream. It is a very important point 
to know exactly what percentage of cream we are using, 
for such mixtures like Biedert's, in which 1 ounce of 
cream is mixed with 3 ounces of water, may agree very 
well when we use a 16- or 20-per-cent. cream, but might 
be disastrous if we use a cream containing 40 per cent, 
of fat. Such infants would not tolerate this rich cream, 
and might have troublesome vomiting. 

CREAM FOR HOME-MODIFICATION. 

Ordinary Cream. — This is made by setting milk at 
night and skimming it in the morning; it is called grav- 
ity, or skimmed, cream, and contains 16 per cent, of fat. 
(134) 



CREAM. 135 

Twelve-per-cent. Cream. — Obtained in the city by 
using equal parts of ordinary (20-per-cent.) centrifu- 
gal cream and plain milk. In the country we must use 
2 parts of ordinary skimmed, or gravity, crearn (16 per 
cent.) with 1 part of plain milk, or by taking the top 
layer of milk, after it has stood five or six hours, by means 
of siphoning. 

Eiglit-per-cent. cream is obtained in the city by dilut- 
ing 1 part of centrifugal (20-per-cent.) cream with 3 
parts of plain milk; in the country, by using 1 part of 
gravity cream and 2 parts of plain milk, or by using the 
top layer of milk that has been standing five or six hours, 
siphoning it off. 

Top-milk is obtained directly from fresh milk by the 
so-called "gravity process." Cream contains a great deal 
of fat, usually three-fifths of cream is fat; this floats on 
the surface of the watery milk. If a quart bottle of the 
average city milk is put into ice-water or upon ice in the 
refrigerator, and removed after four or five hours, we can 
skim off from the top about 10 ounces of an 8-per-cent. 
cream; after six hours about 6 ounces of 12-per-cent. 
cream. This I shall speak of as top-milk. Frequently, 
instead of skimming the cream, the lower portion is si- 
phoned off, leaving the cream in the glass bottle. When 
cream is removed by a centrifugal machine, it is known 
as centrifugal cream. It can be separated much more 
quickly than so-called gravity cream, which must rise 
naturally and slowly from milk that is allowed to stand. 

HOW TO PEOCUEE CEEAM. 

Set aside the ordinary quart bottle of milk on the ice 
for several hours (from six to eight hours) to allow the 
cream to rise. After the cream has risen draw the milk 
from the bottom of the bottle; this can be accomplished 
by means of a siphon. 

To make the siphon get a piece of glass tubing 21 
inches in length and a quarter of an inch in calibre. This 



13G INFANT-FEEDING. 

can be procured in any drug-store. German glass is less 
liable to crack than American glass. If the glass tubing 
is longer than 21 inches make a small scratch in it, after 
measuring off 21 inches, with a three-cornered file; then 
grasp the glass tubing between the fingers and opposing 
thumbs of both hands, having the thumb-nails touching 
each other on the side of the glass just opposite to the 
scratch. On attempting to bend the glass tube it will 
break smoothly across, and if there are any sharp edges 
they can be smoothed by rubbing them down with the 
file. 

To bend the glass tube to the V shape, hold it in 
the flame of an ordinary gas-jet or alcohol-lamp for a 
few moments, twirling the glass rod until it softens suf- 
ficiently to allow it to be bent to the required angle. The 
tube should be w 7 armed gradually at first, and then put 
right into the flame. It is better in bending the glass 
to make one arm of the siphon a few inches longer than 
the other. 

In using the siphon hold it with the angle down, fill 
it with water, and close the long arm with the tip of the 
finger; then, keeping the finger applied to the long end, 
turn the siphon with the angle up, and introduce the short 
arm into the bottle of milk, letting it rest upon the bot- 
tom. On removing the finger, the milk will flow through 
the tube, and continue to do so until the bottle is empty. 
It is, therefore, necessary to watch the layer of cream, so 
that the siphon can be lifted out of the bottle just before 
the cream reaches it. There will thus remain in the milk- 
bottle all of the cream and a small portion of the milk, 
the latter depending upon the expertness of the person 
using the siphon. 

TO PASTEURIZE THE CREAM. 

Take a clear glass bottle having a neck not very wide; 
fit into the same a perforated cork with a chemical ther- 
mometer registering up to 212° F. The bulb of the ther- 



MODIFICATION" OF MILK. 137 

mometer should come within half an inch of the bottom 
of the bottle. The cream is put into the bottle, and the 
cork carrying the thermometer is inserted; the bottle is 
then placed in a pot containing a couple of inches of 
warm water and allowed to heat on the stove. The ther- 
mometer should be watched until it reaches 160, taking 
care that it does not go above 170. When the thermom- 
eter has reached this point, set the pot back on the stove 
where it will cool off, and allow it to remain there for 
twenty minutes. At the end of this time substitute a 
plug of absorbent cotton for the cork containing the ther- 
mometer. Great care must be taken to keep the absorbent 
cotton dry. Cream thus prepared is pasteurized, and will 
keep sweet and fresh for twenty-four hours without being 
kept on ice, and all that is necessary in removing a por- 
tion from the bottle is to be sure that the cotton plug 
does not become moist, or, if it should, to replace it with 
a dry piece at once. 

TO CLEAN THE GLASS SIPHON. 

It is advised to fill it with water immediately after 
using it, and the ordinary tube-brush having eighteen 
inches of wire added to it will permit thorough cleansing. 
Nothing, however, will be found as good as thorough 
boiling in plain water to which a pinch of soda has been 
added. 

Modification of ]\Iilk. 

It has been shown previously that the percentages of 
fat in woman's and in cows' milk are about the same, that 
the quantity of sugar is rather lower in cows' milk, and 
that the quantity of casein and albumin is greater in 
cows' milk, as is also that of the ash. Experience has 
shown that cows' milk must be diluted before it can safely 
be fed to infants. Simply diluting the milk reduces the 
percentages of fat and sugar too much ; so the practice of 
adding cream and sugar has arisen, but the processes that 



138 INFANT-FEEDING. 

have been advocated for obtaining the desired additional 
quantities of fat and sugar have been too complicated for 
general nse. 

The top 9 ounces of a quart of milk on which the 
cream has risen will be about three times as rich in fat 
as the whole milk, the top 15 or 16 ounces will be about 
twice as ricli as the whole milk, while the other ingredi- 
ents remain about the same as in whole milk. 

For babies under 3 months of age the top 9 ounces 
of a quart of milk on which the cream has risen should 
be diluted from 3 to 10 times and 1 part of sugar added 
to 25 parts of food. 

For babies 3 to 6 months old the top 16 ounces of 
a quart of milk on which the cream has risen should be 
diluted 2 or 3 times and 1 part of sugar added to 25 or 
30 parts of food. 

For babies 6 to 9 months old the top 20 ounces of 
a quart of milk on which the cream has risen should be 
diluted 1 / 2 to 1 time and 1 part of sugar added to 50 
parts of food. An even tablespoonful of granulated sugar 
equals 1 / 2 ounce. 

By following this method the infant commences on 
weak mixtures that show about the same composition and 
variations as mothers' milk and gradually takes food richer 
in casein until plain milk is reached. 

The diluents used are water, gruels, or dextrinized 
gruels, which are simply ordinary gruels the starch of 
which has been converted into soluble forms, leaving the 
cellulose and proteids of the cereal in a finely divided 
state. The effect of the different diluents will be men- 
tioned farther on. 

MILK-SUGAR SOLUTIONS. 

1. Take 1 ounce of milk-sugar and 20 ounces 1 

of water, and dissolve. I This makes about a 

Or 1 even tablespoonful of milk-sugar and V 5 - per - cent, sugar 

7 1 / 2 tablespoonfuls of water, and dis- | solution. 

solve. 



MODIFICATION OF MILK. 139 



Makes a 6-per-cent. 



2. Dissolve 1 tablespoonful of milk-sugar in 

6 V2 ounces of water. 
Or 1 ounce of sugar is to be dissolved in { sugar solution. 
16 V2 ounces of vrater. 

3. Dissolve 1 ounce of sugar in 14 ounces of "| 

water. ! Makes a 7-per-cent. 

Or 1 even tablespoonful in 5 1 / 2 ounces of j sugar solution, 
water. 

4. Dissolve 1 ounce of sugar in 12 1 / 2 ounces 

of water. Makes an 8-per-cent. 

Or 1 even tablespoonful in 4 1 / 2 ounces of j sugar solution, 
water. 

5. Double tbe strength of above milk-sugar ) Makes a 10-per-eent. 

(Formula No. 1). i sugar solution. 

ADDITION OF SUGAR TO MILK. 

In order to render milk palatable, sugar must be added 
in some form; hence cane-sugar or milk-sugar has been 
advised. Jacobi insists on the addition of cane-sugar, and 
he agrees with Biedert, who uses it in his cream-mixture. 
That cane-sugar certainly has some virtue can be seen by 
the fact that it is used extensively as a preservative in the 
manufacture of condensed milk. 

Cane-sugar. — Cane-sugar, being far sweeter than 
sugar of milk, it is advisable to use 1 / 2 the quantity that 
would ordinarily be used for sweetening with milk-sugar. 
Cane-sugar is advised in the treatment of constipation; 
frequently we find breast-fed babies who suffer constipa- 
tion, the cause being deficiency in sugar. In such cases 
giving a small lump (about 1 / 2 teaspoonful) of cane- 
sugar dissolved in a teaspoonful of sterile water (ordinary 
boiled water), and this given immediately before putting 
the baby to the breast, will make up the deficient sugar 
and frequently modify a distressing constipation without 
resorting to drugs. 

Contra-indications to the Use of Sugar. — There are 
a great many conditions in which the addition of sugar 
is not onlv contra-indicated, but absolutely harmful. For 



140 INFANT-FEEDING. 

example: If an infant suffers with colic and lias sudden 
attacks (paroxysms) of pain which disturb the infant's 
sleep, such an infant will be found with its legs drawn 
up to its belly, and besides it will utter shrieks while 
crying. The stools will usually be green and sour smell- 
ing, and the abdomen will be found greatly distended 
with gas from fermentation, and frequently the infant 
will have violent eructations. Such an infant usually 
receives an excess of sugar. The treatment of such a 
case is the absolute discontinuance of sugar in the food. 

HOW SHALL WE SWEETEN? 

If constipation has accompanied the infant's ferment- 
ative condition and has also preceded this attack of colic, 
tlien I advise adding glycerin to the milk. It has a very 
sweet taste and a pronounced laxative effect. 

Dose of Glycerin. — For some children half a tea- 
spoonful of glycerin added to each bottle will suffice; 
for others, I frequently use 1 teaspoonful to each bottle, 
rarely more. Glycerin has a pronounced antif ermentative 
effect; being an oil, it is indicated in children requiring 
the addition of fat. It certainly has decided nutritive 
properties. 

SOLUTIONS USED FOR RENDERING COWS' MILK 
ALKALINE. 

Lime-water is trie alkali usually selected for neutral- 
izing the acidity in cows' milk. It acts by partly neutral- 
izing the acid of the gastric juice, so that the casein is 
coagulated gradually and passes, in great part, unchanged 
into the intestine, to be there digested by the alkaline 
secretions. As it contains only 1 / 2 grain of lime to the 
fluidounce, the desired result cannot be attained unless 
at least a third part of the milk-mixture be lime-water. 
Instead of lime-water, 2 to 4 grains of bicarbonate of 
sodium may be added to each bottle, or, better still, from 
5 to 15 drops of the saccharated solution of lime. 



MODIFICATION OF MILK. 141 

This solution is made in the following way: — 

I£ Slaked lime, 1 ounce. 

Refined sugar, in powder, 2 ounces. 
Distilled water, 1 pint. 

Mix the lime and sugar by trituration in a mortar. 
Transfer the mixture to a bottle containing the water, 
and, having closed this with a cork, shake it occasionally 
for a few hours. Finally separate the clear solution with 
a siphon and keep it in a stoppered bottle. 

Bicarbonate-of-Soda Solution (Baking-soda). — Take 
1 grain of soda bicarbonate to 1 / 2 ounce of water. Or 
1 drachm of soda bicarbonate to 1 quart of water. This 
is the proper strength used for diluting milk. 

Quantity to be Used. — One tablespoonful of the last- 
named solution equals in strength 1 tablespoonful of ordi- 
nary lime-water. 

Both lime-water and soda-bicarbonate solution should 
be kept in very clean, well-stoppered bottles and in a cool 
place. 

The writer has seen better results by using bicarbonate 
of potassium (11 per cent.) solution. The addition of a 
half-teaspoonful to each feeding-bottle is well borne and 
beneficial where tendency to colic exists. 



CHAPTER XX. 

Water. 

Of all the necessities of an infant, water stands out 
most prominently. It will aid materially in clearing the 
month and gums and in quenching the thirst. It is cer- 
tainly diuretic, and water given regularly is one of our 
best laxatives. It is a good rule, and one that I insist 
upon, namely: to instruct every mother and nurse that 
a child, young or old. must receive water several times a 
day. 

\ mtity. — An infant up to the first month shall re- 
ceive several teaspoonfuls of plain sterile (boiled) water, 
which has been allowed to cool, but by uo means ice- 
water. 

This drink of water is best given either immediately 
after nursing or feeding or as soon after the feeding as 
possible. 

It is not necessary to awaken the child to give it a 
drink, but if it is not time for feeding and the infant is 
restless, a few spoonfuls of cool water will frequently com- 
fort it. 

TVhen we desire to modify constipation, then water 
will be a most important factor, especially so when large, 
cheesy curds are found in the stool. 

Instances will be found in which some children will 
refuse water: in such cases the addition of a few grains 
of granulated (cane-) sugar will prove advam:_ as. 
Older children, over six months old. can. if properly de- 
veloped, take hold of a glass and be guided in the drink- 
ing or sipping of a wineglassful of water. I advise giving 
at least 3 wineglassfuls of plain sterile (boiled) water per 
day, especially during warm weather. 
(142) 



— - __.. 



:-.: 



The free dilution of children's nourishment with water 
is demanded upon the following additional facts: Only 
to a certain limit will pepsin be furnished for digestive 

ize<L A great quantity of water is necessary fcc assist in 
pepsin digestion- In artificial digestion albnz_:^ often 
remains unchanged until large quantities of acidulated 
water are supplied- Without doubt many disturbances 
of digestion are to be explained by a deficiency of water, 
certainlv manr more than are due to an excess of it. as 
it is so quickly absorbed- 



CHAPTEK XXI. 

BoTTLE-FEEDIXG, OK HaND-FEEDIXG. 

Cleanliness. — The most important point to remember 
is that everything nsed in connection with a hand-f eeding" 
must be scrupulously clean. 

To sterilize milk in a filthy bottle, or to put milk 
contaminated with stable filth or dirt from the udder of 
a cow, or milk containing pathogenic bacteria, into an 
absolutely clean bottle, is surely repulsive. 

Therefore, my first proposition is: "Clean everything 
that is associated with infant-feeding," from the milking 
of the cow, the surroundings of the cow, until the food 
is ready to be fed to our infants. This necessarily implies 
quite an amount of work, which I shall endeavor to detail 
later on. 

Amount to he Fed. — Ssnitkin (investigations at the 
Children's Hospital of St. Petersburg, quoted by Eotch) 
makes the following rule: "The greater the weight, the 
greater the gastric capacity." 

Ssnitkin's table of calculation shows that one one- 
hundredth of the initial weight should be taken as the 
figure with which to begin the computation, and to this 
should be added one gramme for each day of life. 



Initial 
Weight. 

3000 Gm. 
4000 Gin. 
5600 Gm. 



ILIXSTBATIOX OF SSNITKIN'S RULE. 

Early Days. At 15 Days. At SO Days. 



30 Gm. 
(About 1 oz.) 

45 Gm. 
(About l^oz.) 

60 Gm. 
(About 2 oz. ) 



30 + 15 = 45 Gm. 

(About 1^ oz.) 
45 + 15 = 60Gm. 

(About 2 oz.) 
60 + 15 = 75 Gm. 

(About 2 \ oz.) 



30 + 30 = 60 Gm. 

(About 2 oz.) 
45 + 30 = 75 Gm. 

(About 2 § oz.) 
60 + 30 = 90 Gm. 

(About 3 oz.) 



(144) 



CHAPTEE XXII. 



Feeding-table and Cream-mixtures. 



Age. 


Intervals 
of Feeding. 


Number 
op Times 

in 
24 Hours. 


Average 

Amount 

Each 
Feeding. 


Average in 
24 Hours. 


1st week .... 
1st month . . . 
2d month . . . 
3d and 4th mos. 
5th and 6th mos. 


2 hours 

2 hours 
2 J hours 

3 hours 
3 hours 


10 

8 
8 
7 
6 


1 oz. 
1} to 2 oz. 

3 to 4 oz. 

4 to 5 oz. 
6 to 7 oz. 


10 oz. 
12 to 16 oz. 
20 to 30 oz. 
30 to 35 oz. 
34 to 40 oz. 



The above is the feeding-table of George C. Carpenter 
(London). 

biedert's cream-mixtures. 

The following formulae are from trie fourth edition 
of his book on "Infant-feeding," published in 1900: — 



Formula. Cream. Water. Milk-sugar, dfilk. Casein. Fat. Sugar. 

Per Cent. Per Cent. Per Cent. 

4 oz. 12 oz. 4} dr. . . 0.9 2.5 5 

4 oz. 12 oz. 4* dr. 2 oz. 1.2 2.6 5 

4 oz. 12 oz. 4* dr. 4 oz. 1.4 2.7 5 

4 oz. 12 oz. 4£ dr. 8 oz. 1.7 2.9 5 

4 oz. 12 oz. 4| dr. 12 oz. 2.0 3.0 5 

8oz. 3 dr. 24 oz. 2.5 2.7 5 



I. 

II. 
III. 
IV. 

V. 
VI. 



Cream. Milk. Water. 



1. 1st mo. 51V. No. 

2. 2d mo. No. gij. 

3. 3d mo. No. %\v. 



gxij. 
No. 
No. 



Milk- 
sugar, 

ess. 
No. 
No. 



Casein. Fat. Sugar. 

Per Cent. Per Cent. Per Cent. 

V^T- 1.0 2.4 3.8 

alent to 



4. 4th mo. No. Jfviij. No. 

5. 5th mo. No. ^xij. No. 

6. 6th mo. No. ^xvj. o vli J- 



Is equiv- 1 . 

alent to 
Is equiv- .. q 

alent to 

No. Is . e ^i v - 2.3 
alent to 

N Is equiv- „ g 

^°' alent to 4K) 

*iiss Is equiv " 3 2 
« 5llss - alent to 6/i 

10 



2.6 
2.7 
2.9 
3.0 
3.0 
(145) 



3.8 
3.8 
3.8 
3.7 
4.0 



146 INFANT-FEEDING. 

The latter are known as Biedert's cream-mixtures, and 

are quoted by A. Jacobi. 44 

According to recent milk-analyses, it is necessary to 
take 6 per cent, which is equivalent to 5 1 / 2 drachms of 
sugar to 12 ounces of water. It has also been shown that 
cane-sugar in the same quantity as milk-sugar can be used. 
In using Formula 5, especially if an infant is constipated, 
it is advisable gradually to substitute milk for the water; 
thus we take away 1 ounce of water, and add 1 ounce of 
milk, until our formula is: — 

Cream. Sugar-water. Milk. 

4 ounces. 4 ounces. 20 ounces. 

and gradually arrive at a whole-milk feeding; in other 
words, give pure cows' milk undiluted. Biedert claims 
that frequently diluted cows' milk was not well borne, 
especially on weak stomachs, and the change to the cream- 
mixture resulted in decided benefit. Moreover, he be- 
lieves that the cream-mixture is assimilated far better than 
the diluted milk-mixtures not containing cream. 

Thus he claims that the cases of constipation alter- 
nating with diarrhoea and lastly mucous enteritis are those 
in which the cream-mixture will render satisfaction; but 
he advises that a definite rule must prevail regarding the 
amount of fat contained in the cream, and furthermore 
that an 8- to 10-per-cent. cream be used. 

biedeet's dieectioxs foe making his ceeam. 

From 1 to 2 quarts of milk are put into a broad jar 
(glass) on the ice, for no longer than two hours. He then 
removes with a flat spoon from 3 1 / 2 to 7 ounces of the 
thin white creamy layer over the bluish mass of milk. In 
removing the above quantity a small portion of the milk 
will be removed with it. In cases of severe constipation 
Biedert insists on removing pure cream. 



•Therapeutics of Infancy and Childhood." 



CREAM FEEDING. 147 

The above Formula I is for the first month, Formula 
II is for the second month, Formula III is for a child 
from three to four months, Formula IV is for fourth to 
fifth month, Formula V is for the sixth to seventh month, 
and Formula YI is for the eighth to tenth month. 

It is understood that, while feeding, the general 
condition of the child is the criterion, and thus we shall 
frequently be compelled to change the formula for in- 
dividual requirements, some infants requiring far more 
cream than the above-mentioned formulae give them for 
their age and their weight, whereas the great majority 
will require a modification of far less cream than the 
above-given formulas for their age and weight. 

The indiscriminate feeding of cream, to strengthen the 
baby, cannot be too strongly condemned. Many a dyspeptic 
owes his trouble to overfeeding by a too good mother or nurse. 
When cream is added, and the proportion of fat or proteid is 
too large, vomiting will result. Stuffing delicate children with 
cream, regardless of their digestive power, cannot be too 
strongly condemned. lYlicn improper food is given, and the 
infant's stomach is overtaxed, the excess of food irritates and 
may cause vomiting. If, however, the food remains, then the 
gastric mucosa is inflamed by bacterial fermentation of stag- 
nant food. This may result in fermentative gastritis and 
cause' chronic enlargement of the stomach, or diarrhaza. 



CHAPTEK XXIII. 

Home-modification of Milk. 
colt's decimal method (tuttle, gallaudet). 

This is the simplest and easiest-worked method of 
home-modification yet suggested. It is based on the 
metric system, and all the calculations are made in deci- 
mals. 

Three solutions are required: 1. A decimal (10 per 
cent.) cream, or superfatted milk for introducing the fat. 
2. A saccharated (10 per cent.) skimmed milk for intro- 
ducing proteids not carried by the cream. 3. A standard 
(10 per cent.) sugar solution for introducing the lactose 
not carried by the cream or the skimmed milk. Solutions 
1 and 3 only are required when the proteid percentage 
is small. As the child grows older, and a higher proteid 
percentage is necessary, solution 2 is required also. 

Decimal cream is produced by allowing a quart of 
ordinary fresh milk from a mixed herd to stand on ice 
for fifteen hours, and at the end of this time one-fifth of it 
is taken from the top. This averages 15 per cent, of fat, 
and loses about 1 / 2 per cent, each of sugar and proteids. 
If to this we add 1 / 2 its volume of water, a decimal cream 
is obtained, analyzing: 10 per cent, of fat, 2.33 per cent, 
of proteids, and 2.66 per cent, of sugar. From this the 
following formulae, showing the amounts of proteids and 
lactose coincidently introduced with any definite fat-per- 
centage, are easily deduced: — 

Decimal cream in introducing 4 per cent, of fat also 
introduces 1 per cent, of proteids and 1 per cent, of lac- 
tose. Decimal cream in introducing 3.5 per cent, of fat 
also introduces 0.8 per cent, of proteids and 0.9 per cent. 
(148) 



HOME-MODIFICATION OF MILK. 149 

of lactose. Decimal cream in introducing 3 per cent, of 
fat also introduces 0.7 per cent, of proteids and 0.8 per 
cent, of lactose. Decimal cream in introducing 2.5 per 
cent, of fat also introduces 0.6 per cent, of proteids and 
0.7 per cent, of lactose. Decimal cream in introducing 2 
per cent, of fat also introduces 0.5 per cent, of proteids 
and 0.5 per cent, of lactose. 

Saccharated shimmed milk depends on the fact that 
skimmed milk analyzes 4 per cent, of proteids and 5 per 
cent, of sugar. Five per cent, more of lactose is added 
simply for convenience of calculation. This means add- 
ing 1 ounce, by weight, of lactose to 20 ounces of skimmed 
milk. Our solution then analyzes: proteids, 4 per cent.; 
and lactose, 10 per cent. If we wish to add 1 per cent, 
of proteids, we use one-fourth of the total food required 
from solution 2; if 0.5 per cent, of proteids, one-eighth, 
etc., always remembering that we introduce coincidently 
two and one-half times as much sugar. The formulas here 
deduced are also plain: — 

Amount of food in cubic centimetres X 1 / 8 (saccha- 
rated skimmed milk) adds proteids, 0.5 per cent.; and 
lactose, 1.25 per cent. Amount of food in cubic centi- 
metres X V 4 (saccharated skimmed milk) adds proteids, 
1 per cent.; and lactose, 2.5 per cent. Amount of food 
in cubic centimetres X 3 / 8 (saccharated skimmed milk) 
adds proteids, 1.5 per cent.; and lactose, 3.75 per cent. 
Amount of food in cubic centimetres X 1 / 2 (saccharated 
skimmed milk) adds proteids, 2 per cent.; and lactose, 5 
per cent. 

Standard sugar solution is prepared by dissolving 10 
per cent, of lactose in sterile water, or 2 ounces, by weight, 
in 20 ounces of water. 

In calculating formulae four facts only are necessary: 
the quantity of food required; the percentage-formulae 
required; that the standards, except the proteids, are 10 
per cent.; and the quantity of other constituents intro- 
duced with the standards. 



150 INFAXT-FEEDING. 

With these facts in mind, all that is necessary further 
is to reduce the quantity expressed in ounces to cubic 
centimetres by multiplying by thirty, and to multiply this 
product by one-tenth of the constituent to be introduced. 
Examples with and without the introduction of extra pro- 
teids will be given: — 



Single Feeding. 

Fat. P rote ids. Sugar. 

Per Cent. Per Cent. Per Cent. 

Quantity, 2 oz. Formula desired 2.0 0.50 6.00 

Oz. 2 X 30 = 60 cans. X 0.2 = 12 cams. 

decimal cream, adds 2.0 0.50 0.50 

Leaves 0.0 0.00 5.50 

Oz. 2 X 30 = 60 c.cms. X 0.55 — 33 c.cms. 

sugar solution, adds 5.50 

Working formula: 12 c.cms. decimal cream. 

33 c.cms. standard sugar solution. 
15 c.cms. water. 

60 c.cms. 



One Day's Food. 

Fat. Protcids. Sugar. 

Per Cent. Per Cent. Per Cent. 

Quantity, 35 oz. Formula desired 4.0 1.0 6.50 

Oz. 35 X 30 = 1050 c.cms. X 0.-4 = 420 

c.cms. decimal cream, adds 4.0 1.0 1.00 

Leaves 0.0 0.0 5.50 

Oz. 35 X 30 = 1050 c.cms. X 0.55 = 577.50 

c.cms. sugar solution, adds 5.50 

Working formula : 420.00 c.cms. decimal cream. 

577.50 c.cms. standard sugar solution. 
52.50 c.cms. water. 

1050.00 c.cms. 



GENERAL RULES FOR BOTTLE-FEEDING. 



151 



One Feeding. 

Fat. Proteids. Sugar. 

Per Cent. Per Cent. Per Cent. 

Quantity, 5 oz. Formula desired 4.0 1.50 7.00 

Oz. 5 X 30 = 150 c.cms. X 0.4 = 60 c.cms. 

decimal cream, adds 4.0 1.00 1.00 

Leaves 0.0 0.50 6.00 

Oz. 5 X 30 = 150 c.cms. X £ = 18.75 c.cms. 

skimmed milk, adds 0.0 0.50 1.25 

Leaves 0.0 0.00 4.75 

Oz. 5X30 = 150 c.cms. X 0.475 = 71.75 

c.cms. sugar solution, adds 4.75 

Working formula: 60.00 c.cms. decimal cream. 

18.75 c.cms. saccharated skimmed milk. 
71.25 c.cms. standard sugar solution. 

150.00 c.cms. 

General Rules for Bottle-feeding. 



Age of 
Child. 


Frequency 
or Interval 
of Feeding. 


Number of 

Feedings in 

24 Hours. 


Average 

Amount for 

Each 

Feeding. 


Average 

Amount in 

24 Hours. 


From its 

birth until it 

is 1 month 

old. 


2 hours. 


10 


1 to 2 ounces. 


10 to 20 
ounces. 


1 month 
until 

2 months. 


Every 
2£ hours. 


8 


2 to 2£ 
ounces. 


16 to 24 
ounces. 


2 to 4 
months old. 


Every 
3 hours. 


6 or 7 


3J to 4 
ounces. 


20 to 26 
ounces. 


4 to 6 
months old. 


Every 
3 hours. 


6 


5 or 6 ounces. 


30 or 36 

ounces. 


6 to 9 
months old. 


Every 3J to 
4 hours.. 


5 


8 ounces. 


40 ounces. 


9 to 12 
months old. 


Every 
4 hours. 


5 


8 ounces. 


40 ounces. 



152 infant-feedixg. 

• Rules for Feeding. 

For a Child at Birth. Formula 1. — The newborn 
infant's food should consist of (home-modification): — 

Fat 1.0 Cream 2 ounces. 

Sugar 5.0 Milk 2 ounces. 

Proteids 0.75 Lime-water 1 ounce. 

Reaction alkaline. "Water 15 ounces. 

Milk-sugar 6% drachms. 

The above formula (1) is to be divided into 10 feed- 
ings of 2 ounces each, or 60 cubic centimetres each, and 
should be heated for 20 minutes to 167° F., though Prof. 
Russell, of Wisconsin, has proved by experiment that 
tubercle bacilli is destroyed at 140° F., which temperature 
mav answer when a good source of milk is found. 

The cream must contain at least 10 per cent, of fat. 
This is known as a decimal cream, and can be referred to 
under the heading of "Cream for Home-modification." 

Formula for Home Use. 

Child 1 Month. Formula 2. — Take of : — 

Fat 2.0 Cream 4 ounces. 

Sugar 5.0 Lime-water 1 ounce. 

Proteids 0.75 Water 15-25 ounces. 

Lime-water. . .5.0 Milk-sugar 6% drachms. 

The above quantity is to be divided into ten feed- 
ings, and heated for 20 minutes to 167° F., and the in- 
fant to be fed once every two hours. In Formula 2 we 
have added more cream and purposely left out the milk. 
If the infant thrives on this mixture, then we can sub- 
stitute 1 ounce of milk instead of 1 ounce of water. Some 
children will not be satisfied with less than 3 to 4 ounces; 
there is no reason why they should not receive the above 
quantity if their general condition warrants it. 

After the end of the second month the quantity of 
food can be increased if the infant's appetite, sleep, stools, 
and general condition warrant it. Thus, instead of feed- 



SCHEDULE FOR FEEDING AND FORMULA. 



6 
ft 


o 

< 


Ph 


Ph 


O Si 

Oh 3 

PhPh 


hi 


^ 03 

G>0 


I. 


1st and 2d day. 




5.0 




4-8 


125-250 


II. 

III. 


3d to 7th day. 
2 to 4 weeks. 


2.0 
2.5 


6.0 
6.0 


0.60 

0.80 


10-15 
20-30 


310-460 
620-930 


IV. 


1 to 3 months. 


3.0 


6.0 


1.00 


22-36 


680-1110 


V. 


3 to 4 months. 


3.5 


6.0 


1.25 


28-38 


870-1180 


VI. 


4 to 6 months. 


4.0 


6.0 


1.50 


32-38 


990-1180 


VII. 


6 to 9 months. 


4.0 


7.0 


2.00 


34-42 


1050-1300 


VIII. 


9 to 12 months. 


4.0 


6.0 


2.50 


38-45 


118.0-1400 


IX. 


12 to 15 months. 


4.0 


5.0 


3.00 


40-50 


1240-1550 


X. 


15 to 18 months. 


4.0 


5.0 


3.50 


45-50 


1400-1550 


XI. 


18 months 














(whole milk). 


3.5 


4.3 


4.00 


45-50 


1400-1550 



Formula Obtained by Diluting 12-per-cent. Cream. 



Dil. 5 times with 6-per-cent. sugar sol.: 
Dil. 4 times with 6-per-cent. sugar sol. : 
Dil. 3 times with 7-per-cent. sugar sol.: 
Dil. 2J times with 7-per-cent. sugar sol. : 
Dil. 2 times with 7-per-cent. sugar sol. : 

By diluting five times is meant one part of the cream and five 
parts of the sugar solution, etc. 





Fat. 


Sugar. 


Proteids. 




Per Cent 


Per Cent. 


Per Cent. 


II. 


2.0 


6 


0.60 


III. 


2.5 


6 


0.80 


IV. 


3.0 


6 


1.00 


V. 


3.5 


6 


1.20 


VI. 


4.0 


6 


1.30 



Formula Obtained by Diluting 8-per-cent. Cream. 



Dil. once with 10-per-cent. sugar sol.: 
Dil. 1J times with 7-per-cent. sugar sol.: 
Dil. 3 times with 7-per-cent. sugar sol. : 
Dil. 7 times with 5-per-cent. sugar sol. : 





Fat. 


Sugar. 


Proteids 




Per Cent 


Per Cent. 


Per Cent. 


VII. 


4 


7 


2.00 


XII. 


3 


6 


1.50 


XIII. 


2 


6 


1.00 


XIV. 


1 


5 


0.50 



Formulae Obtained by Diluting Plain Milk. 



Dil. once with 8-per-cent. sugar sol. : 
Dil. 3 times with 5-per-cent. sugar sol. : 
Dil. 7 times with 4-per-cent. sugar sol. : 
Dil. 11 times with 4-per-cent. sugar sol. : 



Fat. 


Sugar. Proteids 


Per Cent. 


Per Cent. Per Cent. 


XV. 1.80 


6 2.00 


XVI. 0.90 


5 1.00 


XVII. 0.45 


4 0.50 


XVIII. 0.30 


4 0.34 



154 INFANT-FEEDING. 

ihg a bottle of Formula 2, we simply add 1 ounce of milk 
for the third month to Formula 2. Frequently the ad- 
dition of 1 or 2 ounces of sterile water to the formula will 
give a larger bulk and satisfy the infant. As every in- 
fant's appetite and gastric capacity is different, we must 
carefully note the condition of the baby after its feeding 
before resorting to fixed rules. 

Formula for Home Use. 

At 4 Months. Formula 3. — Take of: — 

Fat 3.5 Cream 7 ounces. 

Sugar 6.5 Milk 1 ounce. 

Proteids 1.5 Lime-water 1 ounce. 

Lime-water. . .5.0 Water 25-32 ounces. 

Milk-sugar 6*4 drachms. 

Divide into eight bottles; heat as above to 167° F. ; 
feed every three hours. 

Formula for Home Use. 

From 9 to 12 Months. Formula 4. — Take of: — 

Fat 4.0 Cream 8 ounces. 

Sugar 7.0 Milk 7y 2 ounces. 

Proteids 3.0 Lime-water 1 ounce. 

Lime-water. . .5.0 Water 20-30 ounces. 

Milk-sugar 6% drachms. 

The above to be divided into five feedings, heated to 
167° F., and one bottle fed every four hours. 

A schedule for feeding an average healthy infant from 
birth upon modified cows' milk, showing percentages of 
fat, sugar, and proteids, and the daily quantity (Holt), 
is given on page 153. 

Clinical, Illustrations or How to Feed (from the 
Author's Private Records). 

Case I. — Baby V., was referred to me for treatment April 3, 
1901. 

The child was 3 y 2 months old at time of commencing treat- 
ment, and weighed 8 pounds and 10 ounces. 

History: Breast-fed about two weeks; since then fed on milk 



CLINICAL ILLUSTRATION'S OF FEEDING. 155 

diluted with water and milk-sugar; food was steamed forty minutes. 

Child had always been constipated, always cries, and suffers with 

colic. 

Gave barley and condensed milk with lime-water; child seemed 

to do well; weight was about 10 pounds. After several weeks cream 
was added to the food. After this addition of cream the child vom- 
ited and cried, had severe colic, was restless by day, and had in- 
somnia at night. Its bowels were so disturbed that all milk was 
stopped. Barley-water was the only food tolerated. Then cereal 
milk was prescribed. The cereal milk was not retained; child vom- 
ited after each feeding, then was constipated, which alternated with 
greenish, dark stools. Infant was emaciated; the stools contained 
mucus. 

Physical Examination: Very emaciated child; temperature, 
100° F.; abdomen distended, very flatulent; skin dry, lost elasticity; 
herpetic eruption on lips and around anus; pulse, 140 and feeble; 
throat clean; lungs normal; heart-sounds very feeble; left inguinal 
hernia. 

Diagnosis: Athrepsia resulting from chronic gastric catarrh. 

Food Ordered: 

Pure cows' milk 2 ounces. 

Oatmeal-water 2 ounces. 

Granulated sugar y 2 teaspoonful. 

Peptogenic powder y 2 teaspoonful. 

Feed every three hours. Alternate with: — 

Pure cows' milk, 

Barley-water of each ^ij. 

Granulated sugar 3ss. 

Peptogenic powder y 2 teaspoonful. 

Heat this mixture slowly for ten minutes, then boil one minute. 

Mother reports that the child takes food well, stools are 
yellow, and child passed a good night, but still has eructations and 
seems colicky. The food was continued, and the child gained ten 
ounces in seven days. 

Weight, April 3 8 pounds and 10 ounces. 

Weight, April 10 9 pounds and 4 ounces. 

Weight, April 17 9 pounds and 8 ounces. 

Weight, April 24 9 pounds and 14 ounces. 

Weight, May 1 10 pounds and 4 ounces. 

Weight, June 3 12 pounds and 5 ounces. 

Weight, June 15 13 pounds and 12 ounces. 

Weight, Dec. 20 19 pounds. 



156 INFANT-FEEDING. 

Extract of malt was ordered, y 2 teaspoonful three times a day. 
Every week the formula was changed, commencing with: — 

Milk 2 ounces 

Barley-water or oatmeal- water. .2 ounces 

One week later I ordered: — 

Milk 2y 2 ounces "1 

Barley-water or oatmeal-water. .2% ounces J 

Feed every three hours. 



> Formula I. 



}■ Formula III. 



Raw milk 3 ounces 

Barley-water or oatmeal-water. . 3 ounces 

Peptogenic powder 2 teaspoonfuls 

Granulated sugar y 2 teaspoonful 

Feed every three or three and one-half hours. 

I ordered this infant to be awakened by day for feeding, but not 
to be disturbed at night. When the child cried after feeding when 
5 months old, instead of giving Formula III, I ordered: — 



Baw milk 4% ounces 

Barley-water 2% ounces 

Peptogenic powder y 2 measure 

Granulated sugar y 2 teaspoonful 



> Formula IY. 



The above for one feeding. Feed every three or three and one- 
hours. Substitute oatmeal-water for barley-water every other day. 

Milk 5y 2 ounces 

Barley-water 2 ounces 



( Formula Y. 
Peptogenic powder y 2 measure 

Granulated sugar y 2 teaspoonful J 

Alternate with oatmeal-water. Feed every three and one-half 
or four hours. 

Case II. — Dorothy L. F., 11 months old, was referred to me for 
treatment on March 18, 1901, by Dr. H. J. 

The history elicited was : The baby is still nursing and appears 
undersized, very anaemic, and poorly developed. No evidence of 
teething; cannot walk nor talk. Has had summer complaint. Re- 
cently suffered with constipation. Had diarrhceal stools some time 
ago; stools were greenish in color, and contained curds and mucus. 
Has had a cough lasting three weeks; also sniffles. A restless 
sleeper, rarely sleeping more than one-half hour at a time during 
the day. Is frequently very raw between thighs and on buttocks. 
Child is very flatulent. 



CLINICAL ILLUSTRATIONS OF FEEDING. 157 

Physical Examination: A very frail child; large abdomen; 
slight evidence of rickets; very feeble heart-action; lungs normal; 
spleen palpable; liver very much enlarged; colon distended, tym- 
panitic on percussion; muscles of extremities very flabby; bones 
very small; epiphyses of long bones very much enlarged; tongue 
coated; throat normal; some adenoids. 

Specimen of breast-milk sent to chemist for examination 
showed: — 

Quantity, about 2 ounces, or 60 cubic centimetres. 
Eeaction slightly alkaline. 

Specific gravity 1.03105 

Fat 1.22 

Sugar 7.07 

Proteids 0.98 

Shows low fat and low proteids. 

The baby weighed about 4 y 2 pounds at birth, and weighed be- 
tween 12 and 13 pounds when 6 months old. It now weighs naked 
about 16 pounds. 

From the history I learned that the mother menstruated while 
nursing since her child was 4 months old. The infant's restlessness 
was evidently associated with this condition. 

The study of the chemical examination of the breast-milk 
which this child received easily explains the poor development, the 
proteids being less than 1 per cent., besides a very low percentage 
of fat being also partly responsible. 

Treatment: Absolute weaning from the mother's breast. 

Pure coios' milk, warmed to feeding temperature, or about 100° 
F., 6 ounces to be given at each feeding. Feed every four hours; 
strict observance of interval of feeding and careful attention to 
sterility of everything coming in contact with food or utensils to 
be used. 

Medication: One-half teaspoonful of malt-extract given three 
times a day. 

This food was not well assimilated, so I ordered y 2 measure of 
peptogenic milk-powder to be added to each 6 ounces of raw milk. 
Gradually heat in a saucepan over a small flame for five minutes, 
then heat more rapidly and boil for about ten seconds. Repeat 
every four hours. Prepare each bottle separately. Do not use the 
food a second time, if the bottle is not emptied at one feeding. 

My record three days later shows: Had a very good night. 
Better appetite, formerly took only 3 to 4 ounces, now takes almost 
5 ounces. Did not moan last night. 

March 27th: Child looks better; bowels move twice naturally, 



158 INFANT-FEEDING. 

and have a yellowish color, but no curds. Temperature, 99° F.; 
pulse, 120; respiration, 30. 

This feeding was continued for about three weeks, and owing 
to good results no changes were made. 

This is the mother's report, which I copy: — 

April 8th: Had a good night; slept from 10.30 p.m. to 6.30 a.m. 
continuously. Bowels are splendid, yellow; three stools yesterday. 
Has a slight irritation of genitals; seems to be fumbling with the 
parts. Examination showed vulvitis, irritation due to scratching, 
slight eczematous intertrigo. 

Diet Ordered: To continue raw milk modified with peptogenic 
powder; in addition thereto beef-soup thickened with either hominy, 
sago, or farina. Feed two hours after milk-bottle once a day, pref- 
erably about noon. Give the child the white of a raw egg with 
sweetened water every other day. The child received soup, alter- 
nating the next day with the white of egg, in the following 
manner: — 

Warm raw milk, modified with pep- 
togenic 6 ounces at 6 a.m. 

Milk, peptogenic 6 ounces at 10 a.m. 

Soup, thickened 6 ounces at 12 Noon. 

Milk, peptogenic . . 6 ounces at 2 p.m. 

Milk, peptogenic 6 ounces at 6 p.m. 

This food was well borne; the child gained. To improve the ap- 
petite 1 minim of nux vomica was ordered three times a day, before 
three feedings. 

Warm or raw milk, modified by heating with peptogenic as di- 
rected above: — 

6 ounces 6 a.m. 

6 ounces 10 a.m. 

White of raw egg, sweetened 12 Noon. 

Milk with peptogenic 2 p.m. 

Milk with peptogenic 6 p.m. 

Malt-extract was discontinued every other week and an emul- 
sion of codliver-oil ordered; 25 per cent, of oil was given. Each 
teaspoonful of the emulsion contained 2 grains each of glycerophos- 
phate of lime and glycerophosphate of soda. 

May 14th: We discontinued giving peptogenic and simply gave 
the baby raw milk warmed immediately before feeding. The milk 
was thickened by giving zwieback and bread-crumbs. I also ordered 
steak-juice, fed several teaspoonfuls at noon with some bread- 
crumbs or cracker-dust, and roast-beef juice. Also ordered egg- 



CLINICAL ILLUSTKATIONS OF FEEDING. 159 

crackers, bread and butter, and soup made with mashed peas in 
■which meat was boiled. 

June 1st: Somatose 1 / 2 teaspoonful to be stirred with milk or 
soup; repeat the dose three times a day. Also ordered raw apple- 
pulp sweetened with sugar. 

June 20th: Discontinued raw white of egg, and gave half of 
soft-boiled egg, half of yolk and half of white, followed by bottle 
of milk at 10 a.m. 

Child now weighs 19 V, pounds. 

Treatment discontinued; child went to the sea-shore. I did not 
see the child until middle of September, three months later. Has 
had summer complaint; food changed; different milk used in 
country evidently the cause. Child now weighs 18 1 / 2 pounds. This 
child did not receive one drop of milk all summer, simply put on 
pea-soup, cocoa and zwieback, and Nestle's food. I ordered: — 

Farina boiled in milk. 

Rice boiled in milk. 

Use one-half milk and one-half water. 

Boil one hour or longer. 

Also some barley-soup, afternoon cocoa, or milk, in the follow- 
ing manner: — 

Milk 4 ounces. 

Water 4 ounces. 

Granulated sugar ... 1 teaspoonful. 
Lime-water 1 teaspoonful. 



Feed at 6 a.m. 



Feed at 10 a.m., same as above. 

Feed at 12 noon, soup made from chicken or beef thickened 
with barley. 



Feed at 2.30 p.m. 4 



Milk 6 ounces. 

Chocolate or 

Cocoa 2 teaspoonfuls. 

Granulated sugar ... 2 teaspoonfuls. 

Water 2 ounces. 



Avoid all lumps in chocolate by rubbing up with hot water 
and gradually adding the milk. Heat over small flame and stir 
well. 

Feed at 6.30 p.m., milk thickened with egg-cracker or zwieback. 

This food was well assimilated, and then the following was 
added: Sliced apple, in the morning; pudding made from broken 
ZAvieback, some milk, and yolk of egg. 



160 INFANT-FEEDING. 

September 30th: Shredded wheat, oatmeal, or farina with milk 
was allowed in addition to the afternoon cocoa or chocolate feeding 
above ordered. At noon chicken bouillon or soup, to which yolk of 
raw egg, well beaten, was allowed. 

In October we gave raw scraped steak on a soda-biscuit. Also 
ordered fresh vegetables, stewed or mashed peas, some spinach and 
cauliflower, and baked potato with butter. 

Bone-marrow, 1 teaspoonful three times a day, was ordered. 

The child made excellent progress. Teeth appeared, and the 
child is strong, well, and able to walk; no physical defect is visible; 
mentally the child is normal, and, indeed, to all appearances it is 
now a normal child. 

Case III. Dyspeptic Infant, Requiring Careful Bottle-feeding, 
now Perfectly Well. — Baby Douglas C. M., child of a physician, was 
bora May 29, 1901. Weighed at birth 9 pounds. Was breast-fed 
about two months. Owing to swollen breasts, the milk suddenly 
ceased. The child was weaned. Weight, 12 pounds. Stools normal 
at time of weaning. Hand-feeding with equal parts of milk and 
water was tried. As this was not well borne, Mellin's food was 
given. 

When first seen by me the infant had frequent attacks of vomit- 
ing; greenish stools, containing curds and mucus. Cries with 
colicky pains. Has constant intestinal fermentation. 

Infant at 4 months, while suffering with colic, was given: — 

Pure milk 14 ounces. 

Barley-water 20 ounces. 

Granulated sugar . . 4 teaspoonfuls. 
Lime-water 7 teaspoonfuls. 

Mix the above and divide into seven clean bottles. Place in a 
refrigerator until required. At feeding-time empty contents of a 
bottle into a saucepan and allow the food to come to a boil, then 
immediately remove from heat. When cooled to feeding tempera- 
ture, give it to the baby. Usual temperature is about 100° F., or 
blood-heat. 

In addition to the above food prune-water, made in the follow- 
ing manner, was ordered for thirst: — 

Fleshy prunes 1 dozen. 

Granulated sugar 3 teaspoonfuls. 

Water 2 teacupfuls. 

Mix together and boil for thirty minutes. Strain; feed when 
cold. Three to 6 teaspoonfuls can be given at one time. 



CLINICAL ILLUSTRATIONS OF FEEDING. 161 

Fresh orange-juice, 3 teaspoonfuls one hour before milk-feeding, 
once a day. 

When seen a few days later it was found that the child had 
had, during the day, five greenish-yellow stools, containing cheesy 
curds. 

Ordered oleum ricini, 1 teaspoonful at 10 a.m. 

Feed at 11.30 a.m. 

Feed at 2.30 p.m. 

Feed at 5.30 p.m. 

Feed at 8.30 p.m. 

If looseness continues, leave out sugar and substitute sac- 
charin, Va grain to each bottle. 
Following day ordered: — 

Milk 20 ounces. -\ 

Barley-water 14 ounces. 



Formula II. 



Sugar 4 teaspoonfuls. 

Lime-water 7 teaspoonfuls. 

Mix the above and divide into seven bottles. Scald each bottle 
before feeding. 

Barley-water is made by adding a tablespoonful of barley to a 
pint of water, boiling for five minutes, straining through cheese- 
cloth, and again adding enough water to make a pint. 

Infant cried and still seemed hungry after feeding, and the food 
was increased: — " 

Whole milk 14 ounces. 

Gravity cream .... 7 ounces. 

Sterile water 20 ounces. 

Cane-sugar 5 teaspoonfuls. 

Mix the raw milk and cream in a clean bottle and add the 
water and sugar. Divide into seven bottles and keep in a refrig- 
erator until feeding-time. Keep bottles well stoppered with ab- 
sorbent cotton. Warm the bottles in hot water at feeding-time. 
Feed every three hours. 

The following day the child had no stool from 2 a.m. to 10 a.m. 
It seems better satisfied after the bottle, and takes food greedily. 

Food changed to: — 

Whole milk 20 ounces. -\ 

Barley-water 14 ounces. 

c A V Formula IV. 

Sugar 4 ounces. f 

Lime-water 7 teaspoonfuls. J 

Divide into seven feedings. Feed every three hours. 

li 



162 INFANT-FEEDING. 

As the above formula agreed, I ordered: — 

Whole milk 21 ounces. \ 

Barley-water 14 ounces. > Formula V. 

Sugar 4 teaspoonfuls. ) 

Scald the milk and divide into seven feedings. Feed every two 
and three-fourths or three hours. 

Gained one pound during the week; has yellowish stools after 
each feeding; no vomiting; cries after feeding; appears dissatisfied. 

Changed feeding to: — 

Whole milk 20 ounces. \ 

Barley-water 12 ounces. > Formula VI. 

Saccharin 3% grains. J 

Divide into seven feedings. Scald the raw milk with hot barley- 
water; then put in ice-chest until feeding-time. Boil two minutes in 
saucepan before feeding. 

Stool after each feeding, yellow, normal consistency, alkaline 
reaction. Child does not sleep well; seems hungry. Food changed 
to: — 

Whole milk 36 ounces. -j 

Barley-jelly 12 ounces. > Formula VII. 

Saccharin 3y 2 grains. ) 

Add 1 teaspoonful of cream to each feeding; discontinue if 
vomiting or if cheesy curds appear in stools. Scald milk as before. 
Feed every three hours. 

To make barley-jelly take 2 heaping tablespoonfuls of barley to 
12 ounces of water, boil down, and again add enough water to make 
12 ounces. 

Child still appears hungry after feeding. Stools less frequent. 
No A^omiting. Has small, rose-colored spots on legs and face. 
Weight, 13 pounds. 

Feeding changed to: — 

Milk 42 ounces. a ^ . TTTTT 

_, y Formula ^ III. 

Cream 2 ounces. J 

Divide into seven bottles and feed every three hours. 

If food does not agree add 1 teaspoonful of Fairchild's pepto- 
genic milk-powder to each bottle and heat for three minutes before 
feeding. 

Ordered two doses of calomel; Vio grain given. 



CLINICAL ILLUSTRATIONS OF FEEDING. 163 

Cliild appears very bright. Has yellowish stools, no colic; ab- 
domen not distended. No evidence of vomiting. Sleeps well all 
night. 

Feeding changed to: — 

Milk 48 ounces. -\ 

Cream 4 ounces. > Formula IX. 

Dextrinized wheat. . 7 teaspoonfuls. J 

Sweeten and heat as before. Divide into seven bottles. 

To make dextrinized wheat take 3 pounds of plain wheat-flour, 
boil in a bag for five hours, then dry in the oven, break open, reject 
the rind, and grate into powder. 

Child did not digest the dextrinized-wheat feeding. Changed to 
pure milk. Child now takes pure milk, 5 to 6 ounces. 

To relieve eczematous excoriation on buttocks, ordered: — ■ 

IJ Calamin 3.0 

Zinc oxide alb 3.0 

Lanolin 30.0 

Apply t. i. d. 

Child does not sleep well at night. Ordered milk steamed in 
double boiler for twenty-five minutes. Child cried very much during 
the last few days; had thin, yellowish stools after each bottle. 

To relieve thin, watery stools ordered: — 

$ Acid. HC1. dibit 2.0 

Essence of pepsin 60.0 

Sig. : Teaspoonful three times a day before feeding. 

Owing to an eczema on the buttocks after applying the salve, 
ordered equal parts of pulverized zinc oxide and talcum dusted over 
salve on buttocks. 

For the loose bowels ordered the rectum and colon irrigated 
with y 2 pint of chamomile-tea to which was added 10 grains of 
tannic acid. Temperature of irrigation, about 105° F. 

Oleum ricini, 1 teaspoonful, internally. 

Changed feeding to: — 

Milk 4 ounces. \ 

Barley-water . 1% ounces. > Formula X. 

Arrowroot ... 1 heaped teaspoonful. J 

Boil, and feed every three or three and one-half hours, alter- 
nating with thickened rice-soup or rice-water, 4 to 6 ounces at one 
feeding. Baby did very well on this diet, assimilated the food, and 



164 INFANT-FEEDING. 

gained in weight. Had one or two yellowish, well-digested stools 
daily. After this improvement I ordered soups and white of egg. 
The child weighed, at 6 months, 18 pounds. The child is per- 
fectly well, walks and talks, and is now in his second year, with 
normal dentition. 



Effect of Heating Milk. 

Pasteurizing and sterilizing are still necessary evils. 
They are really more useful in keeping milk from spoil- 
ing than for any other purpose. The diseases transmitted 
by milk are very few, and are almost invariably due to 
contaminated water and utensils, and should be obviated 
by dairy inspection. Bacterial growth is what is to be 
feared in the milk, and this can be prevented by keeping 
the milk at low temperatures. If the infant's food or milk 
cannot be kept below 50° F., it should be pasteurized or 
sterilized as soon as possible, as, while the bacteria are 
killed by heat, the toxins they produce are not destroyed. 

Heating produces many changes in milk, some of 
which are not thoroughly understood. Boiled milk does 
not curdle with rennet as easily as raw milk, the cream is 
about one-third denser than the cream of raw rnilk, and 
the albumin is rendered insoluble. 

The following table of C. H. Stewart shows the per- 
centage of soluble albumin in milk at various tempera- 
tures: — 

Soluble Albumin Soluble Albumin 
Time of Heating. in Fresh dlilk. in Heated 3Iilk. 

Per Cent. Per Cent. 



10 minutes at 60° C. (140° F.) 
30 minutes at 60° C. (140° F. ) 
10 minutes at 65° C. (149° F. ) 
30 minutes at 65° C. (149° F.) 
10 minutes at 70° C. (158° F.) 
30 minutes at 70° C. (158° F. ) 
10 minutes at 75° C. (167° F. ) 
30 minutes at 75° C. (167° F.) 
10 minutes at 80° C. (176° F. ) 
30 minutes at 80° C. (176° F.) 



0.423 0.418 

0.435 0.427 

0.395 0.362 

0.395 0.333 

0.422 0.269 

0.421 0.253 

0.380 0.070 

0.380 0.050 

0.375 none 

0.375 none 



changes in milk caused by sterilization. 1g5 

Changes in Milk Caused by Sterilization. 

In some late experiments made by Dr. E. M. Hies- 
lancl and published by Dr. B. C. Hirst 45 Dr. Hiesland 
found that by sterilization: 1. The albumin is coagu- 
lated. 2. Casein is less readily precipitated by rennet than 
in normal milk. Acid corrects this condition. 3. Fat is 
freed to a slight extent; fat not freed has a lessened 
tendency to coalesce. 4. Sugar undergoes some change, 
as shown by its lessened dextrorotatory power. 

The considerations suggested by a knowledge of the 
foregoing facts are: — 

1. The coagulation of milk-albumin by sterilization 
may render the milk more difficult of digestion. 2. 
Sterilization interferes with the coagulability of milk by 
rennet, and presumably, therefore, with its digestibility 
by the gastric juice. 3. Tree fat, as found in sterilized 
milk, is probably not readily assimilated in infant-food. 
The fat not free, being inclosed in a less easily destructible 
envelope, is probably slow of digestion. 46 

On the question of sterilized milk the weight of evi- 
dence seems to show that the process, while preventing 
undue fermentation, so changes certain of the natural 
ferments and some of the fats that the milk is less easily 
digested and less nutritious. 47 

At the New York Medical Association's Meeting, 
March 16, 1891, Brush read a paper on "Sterilized Milk," 
in which he objected to the sterilization of milk for in- 
fants' food because the process devitalized it. Among the 
other ways in which the value of the milk was lessened 
by sterilization, he said, was that the soluble albumin was 
made insoluble. He believed that a child raised on steril- 
ized milk would be less robust, and have a constitution 



45 Medical News, January 31, 1891. 
"Medical Record, February 28, 1891. 

47 North American Practitioner, June, 1892, from the "Year-book 
of Treatment" (Lee Brothers & Company). 



1GG 



1XFAXT-FEEDIXG. 



that would more readily succumb to deleterious influences 
than one fed on natural milk. He contended that every 
human being required some living food, and that the 
cause of every scurvy was deprivation of such living food. 
The sterilization of milk for adults was of but little con- 
sequence, as they had other kinds of food; but it became 
a matter of the highest importance to an infant whose 
only food was milk. 48 

Materxa Home Modifier. 

This is a glass apparatus for the modification of cows' 
milk at home, and consists of a glass vessel with pouring- 




Fi<y. 22. 



lip, shaped like a graduate, holding sixteen ounces. The 
outer surface is divided by vertical lines into seven panels; 
one panel shows the ordinary ounce graduation; the six 
others show six different formula?, so arranged as to be 
suitable for the entire first year's feeding. The accom- 



Boston Medical and Surgical Journal, April 9, 1S91. 



MATERIA HOME MODIFIER. 



167 



panying diagram is a more or less accurate reproduction 
of the arrangement of these panels. 

It is possible to obtain other percentages than those 
shown on the panels, by mixing what is called for by two 
adjacent formulae; as, for instance, equal quantities made 
according to Formulas 1 and 2 combined will give: fat, 
2 1 / 4 per cent.; proteids, 0.7 per cent.; sugar, 6 per cent. 



1. 

3d-14th Day. 

Fat, Ifo. 

Troteids, 0.6 ft. 

Sugar, 6 fo . 


2. 

2d-6th week. 

Fat, 2%fo. 

Proteids, 0.8 fo . 

Sugar, 6 fo . 


3. 

6th-llth week. 

Fat, 3 fo . 

Proteids, 1 fo . 

Sugar, 6 fo . 


4. 

11 wk.-5 mo. 

Fat, 3^^. 

Proteids, \y 2 fo . 

Sugar, 7 fo . 


5. 

5th-9th mo. 

Fat, 4?6. 

Proteids, Ifo. 

Sugar, If,. 


6. 

9th-12th mo. 

Fat, $y 2 fo . 

Proteids, 1% fo . 

Sugar, 3% f, . 


Milk 


Milk 


Milk 


Milk 


Milk 


Milk 


Cream 


Cream 


Cream 


Cream 


Cream 








Lime-water 


Lime-water 




Lime-water 








Water 


Water 






Water 


Lime-water 






Milk-sugar 






Lime-water 






Milk-sugar 






Water 






Water 


Cream 




Milk-sugar 








Milk-sugar 


Barley-gruel 


Milk-sugar 








Gr. sugar 










u 





















As may readily be seen, all the formulas call for the 
same ingredients, excepting the sixth, which, instead of 
water, requires barley-gruel, and granulated sugar in place 
of milk-sugar. 

The method of using the apparatus is extremely 
simple. Having decided upon the formula to be used, 
that panel is to be observed to the exclusion of all the 
others. The respective ingredients are then poured into 



168 INFANT-FEEDING. 

the vessel, to the line below the designated substance. 
Thus, milk-sugar is put in first (or, in its absence, gran- 
ulated; and the line with the cross shows to what point 
the latter should be used), then the water, lime-water, 
cream, and milk in the order shown. The whole is then 
stirred, and the result will be a milk whose formula is at 
the top of the panel. The milk used with the apparatus 
should be good average milk. The cream should be the 
light centrifugal cream as obtained in bottled milk (16-20 
per cent.). The water should be hot, to dissolve the sugar. 
The barley-gruel should be prepared in the usual way with 
Robinson's or ordinary barley. 

According to the age and size of the child, the vessel 
must be filled once, twice, or three times to obtain the 
quantity requisite for the twenty-four hours' feeding. 
The pouring into bottles and sterilization are then done 
as usual. Full directions, including a schedule for the 
twenty-four hours' feeding at the various periods of the 
child's growth, accompany the apparatus, which is sim- 
ple, accurate, and economical, making properly modified 
milk of practical value obtainable in places where it has 
hitherto been impossible to get it. 

The materna is adapted for home use only when the 
physician notes results. To intrust an apparatus of this 
kind into the hands of a mother or nurse not conversant 
with the difference in the percentage of fat contained in 
cream is not only wrong, but will prove disastrous to the 
infant so fed before many weeks are over. The author 
recently saw a case of dyspepsia brought about by feeding 
in this careless manner. On the other hand, the appa- 
ratus will serve as a guide to those physicians whose train- 
ing in percentage-feeding requires occasional assistance. 

A very practical "milk-modifying gauge" devised by 
Mitchell has been placed on the market. It can be pro- 
cured from the National Drug Company of Philadelphia. 
It is designed to aid those unfamiliar with home modi- 
fication, and is especially valuable to those distant from 
large cities with laboratories. 



CHAPTEE XXIY. 

Sterilized Milk. 

It. G. Freeman, M.D., in a paper read before the 
Academy of Medicine, New York, May 11, 1893, says, 
of sterilization, that, when milk is sterilized at 212° F. 
(100° C), absolute sterilization is not obtained, but the 
milk is rendered less digestible than it is in the raw state, 
and physicians who have nsed sterilized milk as a regular 
food find that often infants so fed do not thrive. This 
clinical experience, chemists state, is occasioned by the 
many modifications produced in milk by this tempera- 
ture of 212° F., the starch-liquefying ferments being 
destroyed, the casein being rendered less coagulable by 
rennet and therefore being acted upon slowly and im- 
perfectly by pepsin and pancreatin, and the milk-sugar 
being destroyed; these chemical changes begin to be 
marked when a temperature of 176° F. (80° C.) is 
reached, and become more marked as the temperature 
becomes higher. 

In the Medical Age, September 25, 1893, it is stated 
that Dr. Fayel, of Caen, France, says boiled milk is more 
or less indigestible, and is in no respect safer than un- 
boiled milk; the temperature at which milk boils is in- 
sufficient to destroy microbes, and the milk is therefore 
not sterilized, while its density is increased by the boiling 
above that which is suitable for infant-digestion. 

In the Therapeutic Gazette, October 16, 1893, is a 
translation from a communication to the Societe de Mede- 
cine de Lyon, by Crolas. Crolas concludes that boiling 
milk relieves the milk of small quantities of butter, but 
has no action whatever upon the casein or lactose; that 
the boiling increases the quantity of soluble phosphates. 

(169) 



L70 INFANT-FEEDING. 

lie therefore believes that boiled milk as an article of 
food is equivalent, if not superior, to unboiled milk. 

At the meeting of the New York Academy of Medi- 
cine, Section in Pediatrics, May 12, 1892, Dr. A. Jacobi, 
in the discussion upon infant-foods, made the following 
points : — 

It was a great error to suppose that sterilized milk 
was anything like human milk; it required just as much 
modification as though it were not sterilized. 

Alkalinity in cows' milk was always suspicious, for 
it was evidence that it had been "doctored." The most 
dangerous alkali was bicarbonate of soda, for in milk thus 
treated the ptomaine-producing germs develop best. 

"While pepsin was sometimes useful, he objected to its 
indiscriminate use; without an acid it was inert. 

Sugar was required in an artificial food, but he did 
not believe that milk-sugar was best. There was a close 
relationship between milk-sugar and lactic acid. The 
change from one to the other was very rapid. Some 
lactic acid was necessary for proper digestion, but an 
overquantity produced hyperacidity and indigestion. 49 

Excerpt from an address at the Eleventh Inter- 
national Congress, Rome, Italy, April 4, 1S94, by A. 
Jacobi, M.D.: — 

"I shall only dwell upon two articles which have 
taken an improper hold on the imagination of medical 
men and have almost been raised into subjects of super- 
stitious veneration. The use of milk-sugar in the place 
of cane-sugar in children's food to any extent beyond 
what there is in cows' milk, or its exclusive employment, 
is a source of acid gastric catarrh which afterward re- 
quires medicinal correction; it is transformed into lactic 
acid beyond need and proves a detriment, to the full 
conviction of all those who will give the subject proper 
attention. Thoughtful experience is as valuable an ob- 



Yirginia Medical Monthly, June, 1892. 



CHANGES IN MILK CAUSED BY BOILING. 171 

jective addition to our knowledge as a mere chemical or 
theological theory. 

"Xext in order is sterilized milk, on which hundreds 
of thousands of babies are now being fed to the exclusion 
of everything else. ISTobody would teach nowadays the 
feeding on unchanged or unmixed cows' milk to babies 
as a proper course to take, — as a substitute for mothers' 
milk. But sterilized milk has been looked up to as an ob- 
ject of faith and treated as a pope among foods, infallible. 
To feed babies exclusively on sterilized milk has become 
the rage since it was recommended by gentlemen of the 
highest possible standing in science, but, as far as I know, 
little conversant with the art of treating well and sick 
infants. I speak so bluntly because I love babies, one and 
all. 

"Sterilized milk — pasteurized is inferior to it — is 
superior to unchanged cows' milk, slill not human. Of 
7 cases observed this winter of infantile scurvy, — a nutri- 
tive disorder as far as we can make out, — there were 
3 that had been fed, 2 exclusively, 1 for several months, 
on sterilized cows' milk." 50 

The Chemical and Physiological Changes in 
Milk Caused by Boiling. 51 

Milk consists of a multitude of cells suspended in 
serum. The cells are fat-cells, which form the cream; 
the remaining cells are nucleated, and of the nature of 
white blood-corpuscles. The serum consists of water, in 
which is dissolved milk-sugar and serum-albumin, with 
various salts, and, chief of all, casein. The cells, with 
the exception of the fat-corpuscles, are all living cells, 
and they retain their vitality for a considerable time after 
the milk is drawn from the mammary eland. 



60 Medical Record, May 19, 1894. 

51 J. L. Kerr, M.D., CM., F.R.S.E., in the British Medical Jour- 
nal, December, 1895. 



172 INFANT-FEEDING. 

There is reason for supposing that, when fresh milk 
is ingested, the living cells are at once absorbed without 
any process of digestion, and enter the blood-stream and 
are utilized in building up the tissues. The casein of the 
milk is digested in the usual way of other albuminoids, by 
the gastric juice, and absorbed as peptone. There is also 
absorption of serum-albumin by osmosis. The chemical 
result of boiling milk is to kill all the living cells and to 
coagulate all the albuminoid constituents. Milk after 
boiling is thicker than it was before. 

The physiological results are that all the constituents 
of the milk must be digested before it can be absorbed 
into the system; therefore there is distinct loss of utility 
in the milk, because the living cells of fresh milk do not 
enter into the circulation direct as living protoplasm, and 
build up the tissues direct, as they would do in fresh, 
unboiled milk. In practice it will have been noticed by 
most medical practitioners that there is a very distinctly 
appreciable lowered vitality in infants which are fed on 
boiled milk. The process of absorption is more delayed 
and the quantity of milk required is distinctly larger for 
the same amount of growth and nourishment of the child 
than is the case when fresh milk is used. 

Pasteurization of Milk. 

Heating milk to 75° C, as is done by many of the 
methods, does not sterilize, for the spores of the bacillus 
subtilis can withstand this temperature for several days. 
The spores will resist the temperature of 100° C. (212° 
F.) for six hours. Upon heating to 110° to 120° C. 
(230° to 248° F.) the milk will be thoroughly sterilized, 
but such heating causes a browning of the milk, and the 
cream-cells are apt to be broken and the fat or butter will 
rise to the surface. 52 

Pasteurization with a temperature between 60° and 



Molt-Zeitung. 



STERILIZED MILK. 173 

80° C. (140° to 176° F.) destroys tubercle bacilli and, 
according to Van Germs, destroys also trie typhoid ba- 
cillus, the cholera bacillus, and the pneumococcus of 
Friedlander, and also most of the ordinary milk germs, 
and does not injure the milk. 53 

Sterilized Milk. 

Sterilized milk is, according to Marr, 54 as badly borne 
in children's dyspepsias as ordinary milk, for, even when 
sterilized by Soxhlet's apparatus, milk is still prone to 
decomposition, and hence favors the decomposition-proc- 
esses present in the diseased digestive tract. 

Dr. B. Bendix 55 studied the question as to the rela- 
tive value of sterilized and unsterilized milk. In a paper 
recently published he arrives at the following conclu- 
sions: Sterilized and unsterilized milk have an equal 
value in nourishing both sick and well children. The 
change in taste and odor caused by the sterilization is no 
cause for the refusal of the same by infants, as steriliza- 
tion destroys both the pathogenic bacteria, as well as the 
bacteria causing fermentation and decomposition; so he 
believes that it is the duty of every physician to insist on 
substituting sterilized milk when breast-milk cannot be 
had, and, as he believes that sterilization does not cause 
difficulty of digestion, he prefers the latter to pasteurized 
milk. 

Koplik 56 studied the comparative value of sterilized, 
pasteurized, and other milks, and found that some weeks 
pasteurized milk and other weeks a sterilized milk would 
show advantages, which, however, would hardly decide 
for or against either method of preparing the food. The 
author believes that it is rather the food that should be 
looked after than the method of feeding it. 

53 Medical Record, July 2, 1892. 

54 London Medical Recorder. 

55 Jahrbuch fur Kinderheilkunde, 38. 

56 New York Medical Journal, April 13, 1895. 



174 INFANT-FEEDING. 

Sterilization of Milk at 212° F. for Thirty 

Minutes. 

method of sterilizing (soxhlet method). 

Bottle-cleansing. — Always cleanse the bottles thor- 
oughly before using if they are new bottles. It is a good 
plan to give them one good washing by adding a pinch of 
common washing-soda to each bottle, boiling for at least 
five minutes in this soda-water, and then boiling for at 
least a quarter of an hour in ordinary water. The bottles 
are then turned upside down to allow the water to drain 
off. I then insert a large stopper consisting of non- 
absorbent cotton (ordinary cotton, from a dry-goods store, 
which is non-absorbent, is far better than the white ab- 
sorbent cotton). The neck of the bottle is stoppered at 
least three-quarters of an inch. 

Bottle-baking. — If we wish to dry them hurriedly, 
then several of these bottles can be placed in a large 
frying-pan with a piece of pasteboard between each bottle, 
and baked thoroughly dry for about a half-hour. This 
not only dries them, but baking them really sterilizes 
them. 

Place the bottles — previously filled with milk or the 
feeding mixture — in the rack, and set the rack in the 
sterilizing chamber, and cover up tight with the lid and 
hood. 

Fill the reservoir (pan) two-thirds full of water and 
place the apparatus over a moderate fire for one hour. 
If the milk is just from the cow, 40 or 50 minutes are 
sufficient (20 minutes for heating and 20 or 30 minutes 
for sterilizing). 

The sterilizer may be used on a gas-stove (turned 
low), kerosene-stove, or upon an ordinary cooking-stove; 
if over the last, the griddle should not be removed. You 
can tell by a bubbling sound that the sterilizer is working 
all right. If the water is not bubbling with regularity in- 
side, you need more heat. It must not be put on the fire 



STERILIZATION OF MILK. 



175 



without water in the reservoir, and the water should never 

be allowed to get lower than one inch from the bottom. 

With proper attention as to the quantity of water in 

the reservoir no further care need be given to the appara- 




Fisr. 23. 



tus, or to the contents of the chamber, for the prescribed 
time. 

It is not necessary to place the bottles on ice after 
removing them from the sterilizer, but all bottles should 



17G 



INFANT-FEEDING. 



be put into a refrigerator until taken out for feeding, 
leaving in the cotton plugs until it is feeding-time. The 
directions sent out with some sterilizers, that milk will 
keep for days, implies that infant's milk may be prepared 
for several days at once. To this I decidedly object. A 
great many authors have pointed out cases of Barlow's 
disease due to milk which had been sterilized and not used 




Fig. 24. 



for a very long time. Before feeding, the bottle is to be 
properly warmed by putting it into a small measure or 
bottle-holder and heating it with alcohol or gas to about 
the body-temperature of 98° or 100° F. Immediately be- 
fore using shake the bottle, so as to mix the cream and the 
milk, which invariably separate in a refrigerator; remove 
the cotton and draw on the nipple. 



CHAPTEK XXV. 

Pasteurized Milk. 

Booker states that certain germs may not be harm- 
ful to the baby, if introduced into its body, but are in- 
jurious to the milk. For example, bacillus lactis aerog- 
enes. These germs are destroyed at a low temperature. 
Booker does not believe that the disturbances claimed to 
be caused by the sterilization of milk are warranted; nor 
does he believe that sterilized milk per se causes scurvy. 

Freeman states that high-temperature sterilization 
causes chemical changes in milk: — 

Change in taste at 70° C. (158° F.). 

Chemists note changes at about S0° C. (176° F.). 

Freeman believes bottle-food to be a predisposing 
cause of scurvy. He states that a low temperature, pro- 
longed, acts as well in destroying pathogenic germs as 
the action of a high temperature for a short time. He 
advises 68° C, equivalent to 155° F., for 30 minutes, 
followed by rapid cooling. Such a temperature will de- 
stroy the germs of diphtheria, typhoid, tuberculosis, and 
other diseases, proved by the inoculation of a plate at 
laboratory temperature, showing no growth after twenty- 
four hours. Freeman does not believe that our present 
dairy can furnish a raw milk which is absolutely safe as 
an infant-food, because, he says, milk must be obtained 
by pressure on the teats of a cow, and these teats hang 
beneath an udder, which is covered with hair, and from 
the belly of the cow, which is also covered with this same 
hair covering. Moreover, this portion of a cow is par- 
ticularly liable to be soiled with dirt, as it comes in con- 
tact with the ground when the cow lies down. Its hairy 

12 ( 177 ) 



178 INFANT-FEEDING. 

covering, moreover, holds the dirt, which is gradually 
shaken out by friction. If the cow has loose stools, these 
run down the inner surface of the thigh and the posterior 
portion of the udder. The contamination dries on the 
udder, in the air, and during milking is apt to fall as 
dust in the pail. Moreover, the milk-ducts of the cow 
may contain many bacteria, although usually contami- 
nation from this source is not very great. Freeman fur- 
ther says: "The milkman's hands are almost never clean. 
His hands are employed in handling manure, and in 
attending duties involving contamination. Occasionally 
they are used during the day in waiting on some one 
sick with a contagious disease, and, when such is the case, 
the consumers of the milk are apt to suffer." 

The author read a paper by Prof. Adolf Baginsky, 
on "The Milk-supply in the Kaiser and Kaiserin Fried- 
rich Children's Hospital, in Berlin," before the Section 
on Diseases of Children, at Atlantic City, in June, 1900, 
wherein Baginsky says that, before milking a cow, the 
stable is cleaned with a damp cloth. All the dirt is re- 
moved, and finally the stable is cleaned with water. Prior 
to milking, the Swiss milkmen are compelled to thor- 
oughly cleanse themselves, giving especial attention to 
their hands. These are cleaned Avith soap and brush. 
Great stress is laid on washing the udder of each animal 
with warm soap-water, and drying with clean cloths. In 
this manner the infection with hair and stable-dirt is pre- 
vented. The milk is not allowed to remain in the stable 
until all the cows are milked, but as soon as a pail is filled 
it is at once removed to the dairy, thus preventing the 
danger of contamination with bacteria which are found 
in the air of the stable and which are very hard to destroy 
by sterilization. These are the bacteria of the hay- and 
potato- bacillus groups. Another vital point is that warm 
milk easily absorbs the various stable-odors, and frequently 
has a distinct "stable-flavor." 

If what Freeman claims might happen, — namely: 



PASTEURIZED MILK. 



179 



the introduction of filth, manure, and f cecal matter into 
the milk during the milking process, — then it seems to 
me that such milk should be discarded entirely, for it is 
hardly conceivable that sterilizing or pasteurizing can 
modify milk contaminated in such a manner. Following 
the precepts of Professor Baginsky at Berlin, the main 
point is to insist on the strictest "stable-hygiene," and 
thus try to sterilize everything pertaining to the cow, 
the stable, and the ntensils, and in this manner seek to 
obtain, by the strictest attention to cleanliness, "a strictly 
clean milk." 




Fig. 25. — Author's Choice of Feeding-bottle. 



Directions for Pasteurizing Milk. — Pasteurization is 
really sterilization at a temperature of 167° P. Experi- 
ence has shown that the bacteria usually found in milk 
and those which would be harmful for an infant can be 
destroyed by subjecting milk to a temperature of 167° 
to 170° P. for 15 to 20 minutes. Por this purpose Pree- 
man has constructed his pasteurizing apparatus (see Pigs. 
26 and 27), which, however, is rather expensive, although 
extremely useful. The author has used it and has been 
well pleased with the result. 



ISO 



INFANT-FEEDING. 



Freeman's pasteurizer consists of a metal pail into 
which a rack is placed holding the bottles exactly as is 
found in the ordinary sterilizing apparatus. This metal 
pail is partly filled with water — up to its first groove — and 
the water heated to the boiling-point. Until the water is 
brought to the boiling-point, the bottles are not intro- 
duced within the kettle. The bottles, previously filled 
with the required mixture of the infant's food, are held 
in readiness, and, when the water boils in the metal pail, 
the lid is removed, the rack with the bottles placed on 
the inside of the metal pail, and the heat turned off, or the 
pail is removed from the fire. The process consists in 




Fig. 26. 



allowing the water to cool, whereby the bottles and the 
milk get warm for a period of 30 to 45 minutes. After 
45 minutes, the lid is again removed, the metal pail con- 
taining the bottles of milk is taken to a water-trough or 
sink, and the cold-water faucet, over which a piece of rub- 
ber pipe is fitted, is turned on, and the water permitted to 
flow on the inside of the pasteurizer. In this way there 
is a gradual displacement of the warm water by this cold 
water, until the water is all cold. 

After the bottles are sufficiently cooled, they should 
be removed to the refrigerator. The rapid cooling of the 
bottles is as important as the pasteurization by the heat. 
Pasteurized milk should be kept no longer than twenty- 



PASTEUEIZED MILK. 



181 



four hours. We can pasteurize in other ways with any 
ordinary sterilizing apparatus. Thus, the Arnold steam- 
sterilizer (see Fig. 23), leaving the hood off, can be util- 
ized for this purpose. To be sure that we are attaining 
the correct temperature, we can insert a special ther- 
mometer, which is made for sterilizing bottles. It can be 
procured from any chemist or from the Arnold Sterilizer 
Company. 

To pasteurize with any ordinary sterilizer, set a ther- 
mometer into one bottle and put the sterilizer on a brisk 
fire until the thermometer reaches 170° F. Then remove 




Fig. 27. 



to the back of the stove, take out the thermometer, stopper 
the bottle that contained the same, and cover with a hood 
or the lid of the tin pail for fifteen minutes. Then fill 
the inside of the pail with hot water around the bottles 
as near to the top as possible, remove to the sink, and allow 
a stream of cold water from the faucet to displace the 
warm water. A point worth noting is that the cold water 
must not be allowed to splash on the hot bottles, other- 
wise it will crack them. It usually takes about ten min- 
utes to gradually displace the hot water in the tin pail or 
kettle used as a sterilizing chamber, after which the bottles 
of milk are to be placed in a refrigerator and left there 



182 INFANT-FEEDING. 

until ready for use. It is understood that each bottle is 
to be warmed to about a body-temperature of 98° to 100° 
immediately before feeding. 

In a letter recently received by the author Prof. 
Victor Vaughan says he does not believe that milk is 
rendered more digestible by sterilization or pasteurization. 
He thinks that if milk could be obtained under complete 
aseptic precautions, sterilization, as a preparation for in- 
fant-feeding, would not be necessary. However, either 
sterilization or pasteurization is imperative when market 
milk is used, because this is seldom or never obtained 
under aseptic precautions. Some people have an idea that 
it matters not how filthy a milk is, or how many germs 
it may contain, if it be pasteurized or sterilized it becomes 
a fit food for children. This is not true, because, in the 
first place, even prolonged boiling does not kill the spores 
of all bacteria; and, in the second place, the chemical 
poisons produced by certain germs are not altered by the 
temperature of boiling milk. After milk has been either 
sterilized or pasteurized it should be kept at a low tem- 
perature before being fed to the child. This should be 
regarded as a necessary procedure in the preparation of 
infant-food. The fact that milk in which the colon germ 
has already grown abundantly cannot, by any process of 
sterilization or pasteurization, be rendered fit food for 
children should be emphasized. The toxin of the colon 
bacillus may be heated to 180° C. (356° F.) for half an 
hour without having its poisonous properties diminished. 
If clean milk be obtained and pasteurized at from 140° 
to 158° C. and then kept at a low temperature until fed 
to the child, it furnishes the best food which it is possible 
for us to obtain under ordinary circumstances. 



CHAPTEK XXVI. 

Tyndallization. 

Whe^ milk is subjected to a temperature of 212° F. 
for from 15 to 20 minutes on three successive days, such 
process is called tyndallization. When such a procedure 
is instituted, we certainly obtain the "absolutest sterility 
possible" of the milk. 

Such milk, however, is not adapted for infant-feeding, 
owing to the changes brought about by this continued 
application of heat in rendering the albuminoids and salts 
contained in the milk more difficult to digest. 

Milk subjected to this tyndallization has all the dis- 
advantages of a prolonged sterilized milk or milk-mixture. 
My experience is decidedly against such continued heating 
of milk, and I am sure that many cases of scurvy can be 
traced to the lack of fresh albumin and casein assimilated. 

It is certainly peculiar that in spite of the experience 
of many noted men, the author has recently seen a de- 
cided improvement in a child suffering with scurvy when 
the food was changed from sterilized milk to a raw-milk 
mixture, the milk-mixture being merely warmed to a feed- 
ing temperature. 

Barlow's disease can frequently be traced to improper 
feeding, especially when mothers are permitted to- use 
their experience in making up their own feeding-mixtures. 
Children are more frequently starved than will be ordi- 
narily admitted, and, were it possible to examine the food 
given to the average infant and compare it with a stand- 
ard breast-milk suited for the age of the infant, we would 
soon learn that our crude methods resulted in positive 
harm, the result of which years of proper medication and 
feeding will hardly be able to remedy. 

(183) 



184 ix PANT-FEEDING. 

The vital point to remember is to get the child prop- 
erly started, and Ave must not be discouraged if our first 
feeding-mixture is not properly digested or assimilated. 
In such instances we will soon learn which elements of 
our food require more proper modification and elimina- 
tion, especially so if the stools are studied. 

Tyndallization will permit milk to be kept for months, 
and is just such milk which, fed to weakened children, will 
ultimately cause Barlow's disease or its allied conditions. 
While in Berlin several years ago I was given milk which 
had been sterilized six months previously. While it is 
true the taste did not betray the length of time that the 
milk had been kept, it can be easily seen that certain 
chemical changes will develop, altering the character of 
the food. 

It is my belief, founded on extensive experience, that 
sterilized milk, continually fed, to the exclusion of raw 
milk and raw beef -juice, will ultimately result in rachitis 
or scurvy. 



CHAPTEE XXYII. 



Nipples and Bottles. 



Attention to this portion of the feeding apparatus is 
very important, as the canse of sore month and tongue 
and gnms can frequently be traced to a filthy nipple. 




Fie. 28. 



Snch infections can be easily avoided in the following 
manner: The nipples are to be boiled for about ten or 
fifteen minutes in a so-called nipple-sterilizer (see illus- 




tration, Fig. 32), placed in a tin pail of plain water to 
which a pinch of salt has been added. After boiling in 
this manner the nipple should be pnt into a tumbler of 
plain, sterilized (boiled) water and allowed to soak until 

(185) 



1SG 



INFANT-FEEDING. 



it is time to use it. It is advisable to boil every nipple 
immediately after removing it from the feeding-bottle, 
turning it inside out, placing it in the sterilizer, and 
it for 15 or 20 minutes. In this manner all 



steaming 




Fig. 30. 




Fisr. 31. 



pathogenic bacteria are destroyed, and all particles of milk 
which adhere to the rubber are removed. Such nipples 
will not be the cause of stomatitis or other infectious 
mouth disorders. 



NIPPLES AND BOTTLES. 187 

The choice of a nipple is another important matter. 
My preference has always been for a black-rubber nipple, 
and it is a very wise point to use a nipple no longer than 
one week; in other words, old, worn nipples are useless 
for the proper management of infant-feeding. Black 
rubber is softer than white rubber; most white rubber 
is supposed to contain lead; hence a decided reason for 
not using it. 

Nipples Recommended. — One of the best nipples made 
is the so-called anticolic nipple. This nipple has a ball- 
shaped top, which enables a baby to take a firm hold; it 
has three small holes, which give an easy flow of milk, 
and regulate a slow meal. Nipples having very large 
openings, which will permit a baby to finish a 6- or 8- 
ounce bottle of food in five or six minutes, are useless, 
and this gulping of food is really the cause, or one of the 
causes, of infantile colic. 

I have used another nipple, but it is much harder to 
clean, and unless all precautions for sterilization are care- 
fully noted it should not be used; yet, in the hands of the 
intelligent or where we have a trained nurse, it can be 
safely recommended. It is called the "Mizpah." This 
nipple has also a very small puncture, so that the baby 
gets the food slowly. 

The "swan-bill" nipple and the long French nipple I 
also like. I have noted just as good results as with the 
above-mentioned kinds. 

Ventilated Nipple. — A nipple very highly spoken of 
is the ventilated nipple made by Ware, of Philadelphia, 
which has a small opening or valve on the side, and, as 
the milk is drawn in from the bottle, it permits air to 
enter, thus preventing a vacuum from being formed. It 
is also supposed to be non-collapsible, and is highly rec- 
ommended by those who have used it. The only objec- 
tion — already offered— is that all nipples must not only 
be practical for use, but must be capable of thorough 
sterilization. 



188 



INFANT-FEEDING. 



Odor of Nipples. — Children will object most de- 
cidedly to nipples having any odor or taste; hence it is a 
good plan to boil every new nipple before using it. 




Fig. 32. — Nipple-sterilizer. 

The nipple-sterilizer (see Fig. 32) is a very conven- 
ient little arrangement made by Ware, of Philadelphia, 
and resembles a coffee-strainer with a lid. It is neat, 



tf*™^, 




Fig. 33.— Bottle-brush. 

cheap, and serves its purpose admirably for the steriliza- 
tion of the nipple. 

The bottle-brush has a long handle and bristles for 
cleansing the bottles. This brush should be used before 




Fig. 34.— Bottle-brush. 

the bottles are put in the soda solution, and serves for 
cleansing the inside of the feeding-bottles. It is un- 
derstood that the brush can itself harbor bacteria and 
particles of milk removed while cleansing. It is therefore 



FEEDING-BOTTLES. 



189 



important that the brush should be thoroughly boiled in 
a washing-soda solution after each use. 




Fig. 35. 

Feeding-bottles. 

The long 8-ounce feeding-bottle, or so-called feeding- 
tube, which is illustrated, is certainly a unique bottle for 
feeding; as it has no corners and no useless rims, besides 




Ficr 36. 



being smooth on the inside, it can be very easily cleaned. 
All bottles haying angles and depressions should be 
avoided. The boat-shaped bottle is also very good, but 
much harder to clean. 



190 INFANT-FEEDING. 

My preference lias always been for two kinds of 
bottles: 1. Those holding four ounces and graduated on 
one side in both ounces and tablespoons; this saves much 
time and trouble. 2. Bottles holding eight ounces and 
divided off into 16 tablespoonfuls or 8 equal ounces. 

Exactness of Ounces. — It may not be out of place 
to ask each physician to insist on having the graduated 
ounces on an infant's feeding-bottle measured with an 




Fig. 37. — Baby-comforter. Not Advised by the Author. 

accurate graduate, obtainable at every drug-store. In 
many instances the author noted feeding-bottles wherein 
the ounces indicated were very unequal, and one partic- 
ular bottle, graduated to eight ounces, held twelve ounces. 
Long Rubber Tubes. — Most prominent pediatrists 
agree that the long rubber tubes are a convenient place 
for harboring micro-organisms, and they have been uni- 
versally condemned. 



CHAPTER XXVIII. 

Dextrinized Gruels. 

We have previously referred, in the section on "Addi- 
tional Foods during the Nursing Period," to the method 
of making flour-ball. In some instances, especially where 
digestion is subnormal, beneficial results will follow the 
dextrinizing of infant-foods. Thus, the starch of the 
gruel is held in solution, and the remaining cellulose and 
proteids of the cereal are left to act on the curds. 

Method of Dextrinizing. — Prepare the wheat-, barley-, 
oatmeal-, or rice- flour by adding a tablespoonful of the 
same to a pint of water, adding a pinch of salt, and boiling 
the same for from fifteen minutes to one hour. This will 
make a gelatinous solution, and hence the name of barley- 
jelly, rice-jelly, oatmeal- jelly, or wheat-jelly. We allow 
this jelly to cool, and when cool enough to be tasted we- 
can add a diastase, such as cereo; or taka-diastase, made 
by Parke, Davis & Co. ; or the Forbes diastase. When a 
small quantity of this diastase is added to the jellies above 
mentioned, they lose their thickness, and become very 
thin. They can easily be strained through cheese-cloth, 
and some water added to make up for the loss by evapora- 
tion during the boiling. This jelly, or gruel as it is some- 
times called, made from either barley-, rice-, wheat-, or 
oat- jelly, is to be used with the milk after the diastase is 
added. In certain diseases, where milk is not well borne, 
such as dyspepsia (dyspeptic vomiting) or in summer com- 
plaint, where the giving of milk is prohibited, feeding the 
dextrinized gruels for several days will be found, not only 
very useful, but very healthful. In making this dex- 
trinized gruel, small particles will be seen floating, which 
settle out upon standing. These particles consist of the 

(191) 



192 INFANT-FEEDING. 

cell-walls and the proteids of the cereal, and cut the curds 
of the milk into fine pieces, when the curds begin to 
shrink under the combined action of rennet and acid. In 
using this diastase we aim at breaking up the tough curd 
in cows' milk by purely mechanical means. 

Henry D. Chapin {Journal of the American Medical 
Association, July 14, 1900) says: "The next important 
step is to get the cows' milk as nearly as possible in the 
same physical condition as mothers' milk. The diluent I 
prefer to use is a wheat-, barley-, or oatmeal- gruel, the 
starch of which has been digested or dextrinized by the 
action of diastase. A heaping tablespoonf ul of flour, made 
from a cereal, is boiled with about a pint and a half of 
water for fifteen minutes. It is then removed from the 
stove and set in cold water for about three minutes to cool 
it. When it is sufficiently cool to taste, a teaspoonful of 
a preparation of diastase is added, which renders the gruel 
thin and watery. This makes about a pint of gruel, con- 
taining the starches in soluble form, while the cellulose, 
or skeleton of the cereal, acts as a most effective attenu- 
ant of the curd. These digested gruels render the milk- 
curd porous, and also provoke the secretion of the digest- 
ive juices. As diluents, they are a great improvement on 
water. Most of the thick malt-extracts are sufficiently 
active in diastase to produce the desired effect." The 
writer, however, prefers the employment of diastase itself, 
without any of the other malt ingredients, as being both 
speedy and efficient. It can either be produced cheaply at 
home or purchased at the nearest drug-store. A simple 
decoction of diastase may be made as follows: A table- 
spoonful of malted barley-grains is put in a cup, and 
enough cold w T ater added to cover it, usually two table- ( 
spoonfuls, as the malt quickly absorbs some of the water. 
This is prepared in the evening and placed in the re- 
frigerator over night. In the morning the water, looking 
like thin tea, is removed with a spoon or strained off, and 
is ready for use. About a tablespoonful of this solution 



DEXTRIKEZED GRUELS. 193 

can be thus secured, and is very active in diastase. It is 
sufficient to dextrinize a pint of gruel in ten to fifteen 
minutes. Preparations of diastase are made by a number 
of chemists: Forbes; Parke, Davis & Co.; Horlick, and 
others. There is now obtainable an active glycerite of 
diastase known as cereo, which is specially made for the 
purpose of dextrinizing gruels. 

During the past summer, in those critical cases of sum- 
mer complaint in which subnormal digestion existed, the 
author has seen very good results follow the administra- 
tion of any and all of the malt-extracts now in our market. 

Frequently the administration of a teaspoonful of 
malt-extract to an infant immediately before feeding was 
not only relished by the infant on account of the pleasant 
taste of the malt, but certainly aided in the assimilation 
of the food. Parely was more than 3 teaspoonfuls of malt 
ordered during twenty-four hours. Such preparations as 
maltine and also maltzyme gave very good results. The 
malt-extract of Parke, Davis & Co. has a very pleasant 
flavor and seems well borne. 

Frequently, when expense proved an important item, 
sufficient dextrinization of foods could be procured with 
these malt preparations above cited. 

It is claimed by some that most malt preparations de- 
teriorate on standing or if exposed too long; this is cer- 
tainly untrue. 



13 



PART II. 



CHAPTER XXIX. 

Feedixg of Infants ix Incubators. 

When we consider that the usual viability of a child 
is placed at twenty-eight weeks of intra-nterine gestation, 
then we can see how vastly different the method of feed- 
ing must be from that of a child born at term, or a so- 
called "full-born child." 

Method of Feeding. — The size of the child precludes 
the taking of an ordinary-sized nipple, and hence various 
measures have been tried, the most successful of which 
has been, according to the author's experience, feeding 
with a small medicine-dropper at intervals of two hours, 
the quantity varying with the age of the infant. It is 
a good plan, considering the capacity of the infant at 
term to be 1 ounce, to recognize the deficiency in the 
development of not only the size and capacity of the 
stomach, but also its lack of digestive function. Hence 
my plan has been to commence feeding by giving two 
teaspoonfuls of milk diluted with two teaspoonfuls of 
sugar-water; no lime-water and no salt added. 

A prematurely born baby is necessarily doomed with- 
out proper food, and there are so many other factors to 
be considered during its life in an incubator, such as its 
ventilation, its bodily warmth and cleanliness, that too 
much stress cannot be laid on the value of its food. With- 
out breast-milk, therefore, I feel justified in saying: I 
have yet to see the premature infant that will survive, 
and hence I advise procuring breast-milk, containing no 
colostrum-corpuscles, from a woman having a child any- 
(194) 



FEEDING OF INFANTS IN INCUBATORS. 195 

where from two or three weeks to several months old, and 
diluting this breast-milk, as stated above, with a solution 
of cane- or milk- sugar. Voorhees 57 says: "Regarding 
the care of premature babies in incubators, we have relied 
mainly on diluted breast-milk, and have only employed 
cows' milk in weak proportions when it was impossible 
to obtain the former. In our opinion, our results would 
have been much poorer without the help of mothers' 
milk." 

In rare instances, where infants are very weak, and 
seem to doze and will not swallow, a ~No. 7-American 
Tiemann & Co. rubber catheter, having a velvet eye, can 
be attached to a long rubber tube about one foot in length 
and ending in a little funnel, holding several ounces. 
(See illustration, Fig. 40.) With this funnel and catheter 
forced feeding — so-called gavage — can be performed. 
With the infant lying flat on its back, push the catheter 
slowly, but forcibly, through the mouth as far against 
the pharynx as possible, and continue to push the tube 
from the pharynx into the oesophagus and the stomach. 
In all, from five to seven inches, rarely more, will be 
necessary to reach the stomach. The milk, properly di- 
luted with an equal quantity of milk-sugar solution, can 
then be allowed to flow into the stomach, and the cath- 
eter must then be very quickly withdrawn. Such feeding 
should be repeated once in four, five, or six hours, de- 
pending on the requirements of the case. Each infant is 
a law unto itself, and hence no cast-iron rule can be laid 
down, but each individual case should be studied sepa- 
rately and its requirements met as indicated. Thus I 
have found in a premature infant, born at seven months, 
that 6 drachms was enough for one feeding, and this was 
well borne once in three hours. The food consisted of 
equal parts of breast-milk and milk-sugar water. This 
feeding was continued for one week, when the child cried 



"Archives of Pediatrics., May, 1900. 



196 INFANT-FEEDING. 

very much, and, on attempting to satisfy it, the infant 
swallowed 1 1 / 2 ounces. We then alternated each feeding 
by giving a large meal of 1 1 / 2 ounces followed by a small 
meal of 6 drachms, and fed in this manner every two 
hours until the child was three weeks old. We then gave 
1 1 / 2 ounces of food every two hours. The child's stool 
was quite good; it soiled from two to three napkins every 
day, and, when it was very restless, we gave it from 2 to 
3 teaspoonfuls of boiled water, which seemed to satisfy 
it. I would urge the necessity of giving plain, sterilized 
water freely to all infants living in an incubator. The 
increased temperature of its surroundings calls for it; so 
does also the necessity for eliminating through skin, bow- 
els, and kidneys. 

Dangers of Feeding. — Yery small quantities of food 
should be used in gavage — feedings of the mouth or when 
feeding through the nose. E"o more than 4 to 6 drachms 
should be used, and thus we can feel our way. It is a 
good point to remember that, the pharynx being very 
sensitive, the irritation of the tube in passing into the 
stomach may provoke regurgitation of some of this food, 
and frequently vomiting will be produced. In such in- 
stances, if the posterior nares or the pharynx is filled 
with food, the infant can easily suck some of this fluid 
during an inspiration into its trachea, and start up a pneu- 
monia in the same manner as is done by a child having a 
tube in the larynx in the treatment of laryngeal stenosis. 

Rectal feeding for premature infants is rarely called 
for, but it can and should be tried if the infant will not 
swallow and the forced feeding through the mouth or nose 
is unsuccessful. In such instances use very dilute milk, 
thoroughly peptonized, — the same proportions, however, 
as have been stated previously, namely: 1 / 2 milk and 1 / 2 
water. The formula for rectal feeding should be: — 

I£ Breast-milk V 2 ounce. 

Starch-water Va ounce. 



FEEDING OF INFANTS IN INCUBATORS. 197 

Add contents of 1 Fairchild peptonizing tube, and 
inject this quantity with an infant's rectal syringe. (See 
illustration, Fig. 41.) The starch-water is made by tak- 
ing 2 teaspoonfuls of ordinary starch and mixing it 
with 1 / 2 teacupful of warm water (not boiling water) 
and making a milky mixture of the same. This starch- 
water should be made fresh for each feeding. It is ad- 
visable to feed about once every six hours with the above 
solution. 

Cleanse the rectum thoroughly by washing with 1 / 2 
pint of lukewarm, Castile-soap water to remove all fseces 
ten minutes before the nutrient fluid (peptonized milk) 
is injected. 

PREMATURE INFANTS (GRIFFITH). 

Premature Birth. — A child may be born in the sev- 
enth or eighth month of pregnancy, or even earlier, long 
before it is quite ready to live outside of the mother's 
body, and when it weighs not more, perhaps, than two 
and a half or three pounds. We need not necessarily 
despair of the life of a baby, however unpromising it 
seems at first. Children born at six and a half months 
have grown up strong at last, although it is not often 
they survive if born before the seventh month. The 
great need of such a baby is heat, and the maternity hos- 
pitals employ an apparatus, called a couveuse, brooder, 
or incubator, especially devised to supply it. (Fig. 38.) 
For family use, a couveuse may be bought at the instru- 
ment-makers, or hired from some of them. This is, per- 
haps, better, as the apparatus is costly. But with an 
increased degree of attention we may get along fairly 
well without it. If a premature baby is bathed at all 
after birth, the temperature of the water should be 102° 
F., and the greatest care should be taken, while drying, 
to see that the child is not chilled. It should be made 
very warm by swaddling it in raw cotton, head and all, 
leaving only the face exposed, wrapping it about with a 



198 INFANT-FEEDING. 

blanket, and tying it around with a roller bandage. Hot 
bottles should be placed on each side of it as it lies thus 
wrapped up in the bed, and fresh ones be substituted fre- 
quently. A very convenient method is to place the child 
in a baby's bath-tub half -full of raw cotton in which 
numerous hot bottles have been concealed. The child's 
only clothing consists of a diaper and a shirt. The room 
should be kept warm, and especially so when this human 
bundle is unwrapped for its bath. After bathing, it 
should be rubbed with SAveet oil and be rolled up again 
in fresh cotton. Often it is better to omit all bathing, 
and simply to rub with the oil. 

These premature infants lose considerably more in 
proportion to their birth-weight than babies at term. This 
is due to their immature digestive tract; also to the fact 
that they are almost invariably intensely jaundiced. They 
gain very slowly, and, if at the end of two or three weeks 
they have reached their birth-weight, they have done un- 
usually well. 

In some of the babies the color is poor from the be- 
ginning, and at any time they are especially liable to at- 
tacks of cyanosis. For these conditions a little slapping 
to cause a good cry or the administration of oxygen will 
dissipate the blueness. Often a few drops of brandy in 
hot water every two or three hours will prevent further 
trouble. One must be very sure, however, that nothing 
has been aspirated into the larynx. 

A great danger in the care of these babies is their 
susceptibility to infections. The incubator itself is a 
great germ-carrier, and should be regularly disinfected. 
The weakness of the lungs and gastro-enteric tract makes 
the infants especially vulnerable. Unless the air is fil- 
tered, dirt is carried in continuously; consequently the 
streptococcus, staphylococcus, and pneumococcus are al- 
ways present, seeking an avenue of entrance. Through 
the skin in eczematous spots or in areas of irritation; at 
the navel; through the eyes, nose, mouth, larynx, lungs, 



FEEDING OF INFANTS IN INCUBATORS. 199 

stomach, and rectum the bacteria can gain admission. To 
prevent infection the most careful cleansing is always nec- 
essary, both of the incubator and the baby. Undoubtedly 
most of the deaths of our cases could be traced to this 
source. 

Finally, in the carrying out of the above essentials 
in the proper management of the premature infant, we 
require the most patient and painstaking attention on the 
part of the nurse, and upon her conscientiousness depends 
the chance of its survival. 

Results. — The statistics are taken from 2314 births 
which occurred at the Sloane Maternity Hospital. 

Four hundred and ten of these babies were prema- 
ture, but of these 74 were still-births, which include mac- 
erated foetus, and still-born babies of cases of placenta 
prsevia, accidental hemorrhage, eclampsia, and the like, 
leaving 336 for treatment. 

Among these cases were a set of triplets, and there 
were 18 pairs of twins; 85 were treated as infants at 
term, and of these 4 died, — a mortality of 4 1 / 2 per cent.; 
145 were put in cotton, and of these 12 died, — a mor- 
tality of 8 per cent. Some of this class should have been 
placed in the incubator, but for lack of room it was im- 
possible; 106 were incubator babies. 

These are divided into two classes: 1. Those that 
died within four days of birth. 2. Those that lived 
longer than four days. 

Twenty-nine of the incubator babies died within four 
days. All of these but 3 were more or less asphyxiated 
at birth ; 9 were breech cases, and of these 5 were difficult 
extractions; 3 after an accouchement force in placenta 
previa. The rest were vertex presentations, but of these 
2 were forceps deliveries; 6 were under 7 months of 
uterine gestation; 22 were between 7 and 8 months along, 
and 1, 8 1 / 4 months. 

The etiology of the premature labor was an endo- 
metritis in 14; syphilis in 2; albuminuria in 1; placenta 



200 INFANT-FEEDING. 

praevia in 3; accidental haemorrhage in 1; persistent 
vomiting in 1; twin in 1; violence in 1; and in 4 the 
labor was induced. The largest baby weighed 5 2 / 16 
pounds; the smallest 2 7 / 16 pounds. Only 5 infants 
lived over twenty-four hours; 24 were in such poor con- 
dition at birth that they survived only a few hours. In 
16 autopsies were held, and in all of these there were 
marked atelectasis; in 7 haemorrhages of some degree, 
either into the brain or into the serous membranes; in 
2 the foramen ovale was still patent. 

Seventy-seven incubator infants survived the first 
four days; 51 were children of primiparae, 27 of whom 
were out of wedlock; 3 infants were under 7 months of 
gestation, 8 were over 8 months along; 9 were breech 
presentations; 1 a transverse and the rest vertices; 2 
were of triplets associated with albuminuria; 18 were in 
twin deliveries, associated with albuminuria or hydram- 
nios. The cause of the premature labor was endometritis 
in 27; syphilis in 4; phthisis in 2; albuminuria in 7; 
accidental haemorrhage in 1; placenta praevia in 1; in 
2 the labor was induced for albuminuria and eclampsia; 
1 was a Caesarean section; another an ectopic gestation; 
the cause of the rest was unknown. Seven were delivered 
by forceps; 2 by a version; 1 by accouchement force; 1 
by Caesarean section, and the ectopic gestation by a lapa- 
rotomy; 12 were slightly asphyxiated at birth; 9 mod- 
erately so, and 5 deeply asphyxiated; 2, after one and 
a half hours' work of resuscitation, were put in the in- 
cubator head downward, and their condition was so poor 
that they were expected soon to die, but they left the 
hospital gaining in weight ; 5 weighed less than 3 pounds ; 
38 between 3 and 4 pounds; 33 between 4 and 5 pounds; 
1 over 5 pounds; the average weight was 3 12 / 16 pounds. 
During their incubator-life 28 had one or more attacks 
of atelectasis. All but 10 were more or less jaundiced. 
The initial loss of the infants was from 1 to 17 1 / 2 ounces; 
the average was 7 ounces. These figures are not quite 



FEEDING OF INFANTS IN INCUBATORS. 



201 



correct, as the babies were Aveighed at different intervals, 
some on tbe fifth day, some on the seventh day, and 
others not till the fourteenth day. 




Fig. 38. 



202 INFANT-FEEDING. 

The period of loss was from five to twenty-two days, 
the average, eleven days; 10 lost steadily till death; one 
baby was in the incubator only three days, while another 
lived there eighty-two days. The average time was nine- 
teen days. Some were removed early to make room for 
others who needed the place more urgently. 

Only 3 of the 77 cases vomited. The stools were 
normal in 32. 

One was discharged from the hospital as early as the 
eleventh day, and others also too soon at their mothers' 
demand. One was 89 days old; the average was 24 days. 

In 16 diluted breast-milk was supplemented, at times, 
with a mixture of cows' milk and water, with Russian 
gelatin and lactose. In 10 a 1, 6, 0.33 modification was 
used. In all the rest diluted breast-milk was relied upon. 
Twenty-seven never nursed at the breast; of these, 12 
died. A few nursed as early as the third or fourth day 
two or three times a day. Others not for three weeks, 
and one not till the sixty-eighth day. Of the 77, 13 died 
in the hospital: a mortality of 16 per cent. The cause of 
death was atelectasis and bronchitis in 7, acute asphyxia 
from a curd in the larynx in 1, syphilitic pneumonia in 
1, cerebral haemorrhage in 1, gastro-enteritis in 3, and 
a patent foramen ovale and ductus arteriosus in 1. The 
condition of 3 was poor at the time of discharge, fair 
in 24, and very good in 37; 32 were above their birth- 
weights, and 57 were gaining in weight. To letters 
written about January 1, 1900, no answer was obtained 
from 28. Thirteen were reported as having died, 1 of 
these lived fourteen months, 1 nine months, 1 four and 
one-half months, 3 lived two months, 6 lived six weeks, 
1 only a month. Five of these died at the Nursery and 
Child's Hospital and 2 died at Bellevue Hospital. They 
were bottle-fed, and the probable cause of death was 
gastro-enteritis. Twenty-one were found to be alive and 
doing well. Some had nursed and the others were bottle- 
fed. The oldest baby was twenty-two months, and al- 



FEEDING OF INFANTS IN INCUBATORS. 



203 



most all were good, healthy children. One baby at seven 
months weighed 16 pounds. It weighed 4 1 / 16 ponnds 
at birth, and nnrsed from its mother after leaving the 
hospital. The ectopic and the Cesarean babies were in 
beautiful condition. 



Incubators. 


Tarnier. 

Per 

Cent. 


Charl.es. 

Per 

Cent. 


Sloane 

Hospital 

Per 

Cent. 


At the Sloan e 
Hospital, not 

Counting 

those which 

Died in a Few 

Hours. 

Per Cent. 


Saved at 6 months. 
Saved at 6J months. 
Saved at 7 months. 
Saved at 1\ months. 
Saved at 8 months. 


16 
36 

49 

77 
88 


10 
20 
40 

75 


22 
41 
75 
70 


66 
71 

89 
91 



The incubator here described (see illustration, Fig. 
38) is the one used at the Sloane Maternity Hospital. 
There are a great variety of these incubators, but the one 
made by the Kny-Scheerer Company in this city will an- 
swer all requirements. Owing to its expense, the manu- 
facturers will lend an incubator for a nominal sum per 
month. 

Food used in an incubator when breast-milk was not 
obtainable; baby gained in weight and took diluted cows' 
milk after five weeks. Of goat-milk, diluted with sterile 
water : — 

Goat-milk 1 part ; 

Sterile water 4 parts ; 

Milk-sugar Va teaspoonf ul ; 

Peptogenie 1 / i measure, 

heated five minutes, 1 ounce was fed with a medicine- 
dropper to a premature baby every two and one-half 
hours, later every two hours, with excellent results. 



CHAPTEE XXX. 

Aerated Milk. 

Aeration of Milk. — Milk when drawn from the cow 
contains a certain amount of dissolved gases. These gases 
contain more or less of what is known as animal odor, the 
amount of this odor depending very largely upon the 
physical condition of the animal at the time the milk is 
drawn. Sometimes the amount is very slight and scarcely 
noticeable ; at other times it is so great as to be extremely 
offensive. These gases and the accompanying odor are 
easily removed from the milk by exposure of the milk to 
the air during the process of cooling, and to this extent 
aeration of the milk is an advantage. Various forms of 
aerators and combined aerators and coolers have been 
devised, many of which are simple and effective, and the 
best results follow their use. In order to secure these 
results by aeration, however, it is necessary that the ap- 
paratus used for aeration should expose the milk thor- 
oughly to the air, should not be cumbersome, and should 
be simple and easily cleaned; moreover, the process of 
aeration should always take place in the purest atmos- 
phere possible. 

Certified Mile:. 

Dr. H. L. Coit organized a medical commission in 
Newark, "N. J., which has made agreements w T ith the 
dairymen compelling them to look after the details per- 
taining to the food, the selection of the cows, and — most 
particularly — the handling of the milk. All this is under 
the supervision of the Medical Commission. A veterinary 
surgeon is employed for the inspection of the animals. 
In like manner a chemist and bacteriologist see that the 
(204) 



CERTIFIED MILK. 205 

milk is kept to the standard requirements of composition 
and purity. The milk is delivered in bottles, which are 
labeled "Certified Milk." This plan has proved to be 
very successful, and certainly deserves imitation. 



CHAPTER XXXI. 

Proprietary Ixfaxt-foods. 

There Lave been a great number of infant-foods and 
seemingly a great variety placed upon the market and ex- 
ploited by the makers as suitable for the artificial feeding 
of infants. 

These infant-foods may be broadly classified under 
two heads of (A) infant-foods in which coavs' milk desic- 
cated is a constituent, and (B) infant-foods to be used 
with and as adjuncts to fresh cows' milk. 




Fig. 39. — Feeding-cup, after Period of Weaning. 



The infant-foods of which dried milk is a constituent 
are made from cereals and cows' milk. The milk is desic- 
cated in the process of manufacture, and these foods are 
commonly known as dried-milk foods, although in this 
class of foods milk-solids constitute but from one-eighth 
to one-fourth the substance of the foods, the balance con- 
sisting of matters derived from cereals. In some of these 
foods the starch of the cereals is untransformed, and they 
(206) 



PROPRIETARY IXFAXT-POODS. 207 

may be termed farinaceous dried-milk foods. In others 
the starch of the cereals has been transformed into dex- 
trin and maltose, and they may be termed malted dried- 
milk foods. 

All attempts to preserve whole cows' milk by evapo- 
rating it to dryness have been failures; the fat of desic- 
cated milk soon acquires a rancid flavor, and the caseous 
matter does not properly dissolve in water, as the drying 
process destroys its colloidal condition. In the dried- 
milk foods the caseous matter of the cows' milk is inti- 
mately mixed with the other ingredients, but its colloidal 
condition has been destroyed, and it is in the form of fine, 
hard, granular particles, very sparingly soluble in water. 

The group of infant-foods used as adjuncts to cows' 
milk are either farinaceous foods, made from cereals and 
consisting largely of unconverted starch ; or malted foods, 
also made from cereals, but having the starch transformed 
into soluble maltose and dextrin. As fresh cows' milk is, 
without doubt, the best generally available material for 
the artificial feeding of infants, the foods of the latter 
class, used for the modification of fresh cows' milk, are 
more in accord with physiological principles than are the 
dried-milk foods. 

Of the large number of infant-foods that have been 
put on the market, it is our purpose to describe a few 
commonly known foods. In order to judge fairly of the 
nutritive value of an infant-food and its resemblance to 
woman's milk, it is necessary to know its composition 
after its preparation for the nursing-bottle according to 
the directions of its manufacturer, and the analyses that 
accompany the following descriptions are of the foods 
prepared for use for infants six months of age as per 
directions on the packages. 

The published analyses of woman's milk show the 
great variability of its composition, especially as regards 
the percentages of proteids and fats. The analysis of 
woman's milk used in the following tables is bv Dr. Luff, 



208 INFANT-FEEDING. 

adopted as the standard by Cheadle. It agrees closely 
with Leeds's analysis, excepting as to the fat, which is 
given by Luff as 2.41 per cent, and by Leeds as 4.13 per 
cent.; the latter amount seems too large, as it exceeds 
considerably the published averages of a number of ob- 
servers. 

nestle's food. 

RTestle's food is a farinaceous dried-milk food of Class 
A. According to the manufacturers, it is made "from 
the richest and purest cows' milk, the crust of wheaten 
bread, and cane-sugar," and is a "form of modified milk." 
"No cows' milk is to be added to Pestle's food; nothing 
but water, and that water is boiled." 

Upon examination, unconverted starch and cane- 
sugar are found to be its principal constituents, amount- 
ing to about 70 per cent, of the whole. The directions 
for preparing Nestle's food for the nursing-bottle, for in- 
fants six months old, are to use 2 level tablespoonfuls of 
the food to 1 / 2 pint of water; mix the food with enough 
warm water to make a smooth paste that will pour, add 
the rest of the water and boil in a sauce-pan, stirring 
constantly until it thickens and a milky foam appears on 
the top. 

Composition of Nestle's 

Food, 58 when Prepared 

as Above. Woman's Milk. 

Water 92.76 88.51 

Salts 0.13 0.34 

Proteids 0.81 2.35 

Fat 0.36 2.41 

Starch 1.99 

Cane-sugar 2.57 

Maltose, dextrin, etc 0.44 

Milk-sugar 0.84 6.39 

Reaction alkaline. Reaction alkaline. 



53 According to Chittenden. 



PROPRIETARY INFANT-FOODS. 209 

Tlie mixture owes its thick condition mainly to the 
insoluble starch present. The total carbohydrates therein 
(5.84 per cent.) are somewhat less than the carbohydrate, 
milk-sugar (6.39 per cent.), in woman's milk; it is to be 
noted that of this amount 1.99 per cent., or about one- 
third, consists of insoluble starch. 

The fat is nearly one-sixth and the proteids are about 
one-third of the amounts in woman's milk, and over one- 
half of the proteids is insoluble, owing to the colloidal 
condition of the milk-casein having been destroyed by 
drying during manufacture. 

horlick's malted milk. 

This is a malted dried-milk food of Class A, stated 
on the circulars to be composed of pure, rich, cows' milk 
combined with an extract of malted grain, and not to re- 
quire the addition of cows' milk. Its makers claim that, 
by special treatment with their new agent, plant-pepsin, 
the casein, or cheesy part, of the cows' milk is kept from 
forming large and irritating curds in the stomach. 

The directions for preparing the food for an infant 
six to twelve months of age are to dissolve 4 to 6 tea- 
spoonfuls in 1 / 2 pint of water. Composition when pre- 
pared by using 6 teaspoonfuls of food to 1 / 2 pint of 
water : — 

. HorllcTc's Malted Milk. 59 Woman's Milk. 

Water 92.47 88.51 

Salts 0.29 0.34 

Proteids 1.15 2.35 

Fat 0.68 2.41 

Maltose and dextrin 4.20 

Milk-sugar 1.18 6.39 

Reaction alkaline. Reaction alkaline. 

This food is very nearly soluble in water, as its prin- 
cipal constituents are the soluble carbohydrates — maltose, 



According to Chittenden. 

14 



210 INFANT-FEEDING. 

dextrin, and milk-sugar. The drying process lias de- 
stroyed trie colloidal condition of the caseous matter of 
the milk, and it is in the form of finely powdered, hard 
particles, sparingly soluble in water. 

The proteids, fat, and carbohydrates are all less than 
in woman's milk, the proteids being not quite one-half 
and the fat not quite one-third of the amounts in woman's 
milk. The amount of milk employed must be very small 
in proportion to the cereal constituents, since the mixture, 
prepared as above, corresponds to a dilution of 1 part of 
good cows' milk with about 4 parts of water. 

MILKIXE. 

This is a malted dried-milk food (Class A). Its mak- 
ers state it is a complete food ready for immediate use by 
the addition of water, and the only prepared food that 
combines the nutritive elements of meat, milk, and cereals. 

In this malted dried-milk food, beef-extract is com- 
bined with cereal extractives and dried milk. Soluble car- 
bohydrates are its principal constituents, forming nearly 
three-fourths of the product. The proteids are sparingly 
soluble. 

The directions for preparing milkine for an infant 
three to six months of age are to dissolve 1 to 2 dessert- 
spoonfuls of food in a breakfastcupful of water. 

Composition when prepared with 2 dessertspoonfuls 
in a breakfastcupful of water: — 

MilJcine. Woman's Milk. 

Water 92.78 88.51 

Salts 0.23 0.34 

Proteids 0.92 2.35 

Fat 0.43 2.41 

Maltose, dextrin, etc 4.74 

Milk-sugar 0.90 6.39 

Reaction alkaline. Reaction alkaline. 

The total solids are hardly two-thirds of the amount 
in woman's milk. The fat especially is greatly deficient, 



PROPRIETARY INFANT-POODS. 211 

being only about one-sixth of the amount in woman's 
milk, and the proteids are but two-fifths of the amount 
in woman's milk. 

A dilution of 1 part of good cows' milk with about 
7 parts of water will contain about the same amount of 
milk as milkine prepared as above. 

CEREAL MILK. 

Cereal milk is a malted dried-milk food (Class A). It 
is stated by its makers to be a complete food, cooked and 
ready for use with the simple addition of water, and to 
be made from the purest Vermont dairy-milk, the finest 
wheat-gluten flour, the best barley-malt, and milk-sugar. 

Cereal milk in general appearance very much resem- 
bles the other malted dried-milk foods, but it contains a 
much greater percentage of milk-sugar, showing that this 
substance is used in its manufacture, as claimed. 

The directions for preparing it for use are to mix 1 
teaspoonful of cereal milk in a teacupful of hot water 
for infants under three months of age or for a very deli- 
cate child. For older and stronger children 1 to 2 tea- 
spoonfuls of food are to be used to each cupful of water. 
Composition when prepared by using 2 heaping teaspoon- 
fuls of food to a teacupful of water :-^— 

Cereal Milk. Woman's Milk. 

Water 92.52 88.51 

Salts 0.16 0.34 

Proteids 0.69 2.35 

Fat : 0.30 2.41 

Maltose, dextrin, etc 4.73 

Milk-sugar 1.60 ' 6.39 

Reaction alkaline. Reaction alkaline. 

The total of soluble carbohydrates as above is prac- 
tically the same as in woman's milk; the amount of pro- 
teids is less than one-third the amount in woman's milk, 
and about one-half is insoluble in water. The amount of 
fat is one-eighth the amount in woman's milk. The small 



212 INFANT-FEEDING. 

amount of fat indicates that the cereal extractives and 
milk-sugar make up the bulk of the solids of this food, 
and that a dilution of 1 part of good cows' milk with 
11 parts of water would be the counterpart of the above 
mixture as to the amount of milk therein. 

wampole's milk-food. 

Wampole's milk-food is a malted dried-milk food 
(Class A). Its makers state that it is made from malted 
cereals, beef, and milk, and when mixed with warm water 
it is immediately ready for use; no other preparation 
necessary. 

This dried-milk food is very nearly soluble in water, 
owing to the soluble carbohydrates being so large a con- 
stituent. A little less than one-half of the proteids is 
insoluble in water. A small amount of beef-extract has 
been combined with the cereal extractives and dried milk. 

To prepare it for an infant six months to one year of 

age, the directions are to dissolve 4 to 6 teaspoonfuls of 

the food in 6 ounces of hot water. Composition when 

prepared by dissolving 6 teaspoonfuls in 6 ounces of 

water: — 

Wampole's Milk-food. Woman's Milk. 

Water 88.59 88.51 

Salts 0.46 0.34 

Proteids 1.58 2.35 

Fat 0.73 2.41 

Maltose, dextrin, etc 7.65 

Milk-sugar 0.99 6.39 



Reaction alkaline. Reaction alkaline. 

Compared with woman's milk it is seen that the car- 
bohydrates are considerably in excess, and the proteids 
and fat are deficient, the fat especially, it being less than 
one-third the amount in woman's milk. 

One part of good cows' milk diluted with about 3 1 / 2 
parts of water would be analogous to the dilution of milk 
in Wampole's milk-food prepared as above. 



PROPRIETARY IXFAXT-EOODS. 21. 



IMPERIAL GEAXTM. 



Imperial granum is a farinaceous food to be used as 
an adjunct to cows' milk (Class B). 

Its makers state that it is a solid extract derived from 
very superior growths of wheat, nothing more. It appears 
to be made as claimed from wheaten flour and to be mainly 
composed of torrefied starch. 

For an infant six months of age it is to be prepared 
by cooking 3 1 / 2 teaspoonfuls of food in 21 ounces of 
water and 20 ounces of milk. 

Composition when prepared as above: — 

Imperial Gramim.™ Woman's Milk. 

Water 91.53 88.51 

Salts 0.34 0.34 

Proteids 2.15 2.35 

Fat 1.54 2.41 

Starch 1.22 

Maltose, dextrin, etc 0.58 

Milk-sugar 2.71 6.39 

Reaction alkaline. Reaction alkaline. 

The total of solids contained is one-quarter less than 
in woman's milk; the carbohydrates are nearly one-third 
less than the amount in woman's milk and it should be 
observed that 1.22 per cent., or about one-fourth of them, 
consist of starch; there is only a slight deficiency in the 
amount of proteids, but a considerable deficiency in the 
amount of fat. By using more milk or milk and cream 
and less water than above employed the percentages of 
fat, proteids, and soluble carbohydrates would be in- 
creased. 

Its very large proportion of starch forms the principal 
objection to this food. 

The presence of unconverted starch causes the thick 
condition of the mixture. 



60 According to Chittenden. 



21-i INFANT-FEEDING. 



eskay's ALBUMENIZED FOOD. 



This food is to be prepared with cows' milk (Class B). 
Its makers state, in recommending their product, that it 
contains the more easily digested cereals, combined with 
egg-albumin. 

Eskay's albumenized food consists largely (about 88 
per cent.) of carbohydrates; the soluble carbohydrates, 
mostly milk-sugar, are about 50 per cent., and the insol- 
uble carbohydrates, mostly starch, are a little less than 40 
per cent. On account of this proportion of starchy matter 
in the dry food, it may be termed farinaceous. The mak- 
ers, however, claim that in the process of manufacture the 
starch-granules are almost entirely disintegrated, and when 
the food is prepared with milk according to directions the 
percentage is said to be not over 1 1 / 2 to 2 per cent. An 
analysis of the dry food shows that it contains about 9 
per cent, of proteid matter, but when prepared accord- 
ing to the six months' formula it analyzes about 2.55 per 
cent. 

The egg-albumin is said to be first combined with 
sugar of milk in such a thorough manner that the parti- 
cles are finely subdivided, and no firm, hard coagulum can 
therefore take place in the stomach. The particles retain 
their identity, and do not coalesce ; so that in the finished 
preparation the egg-albumin is suspended throughout the 
whole mixture in very fine particles, which are easily di- 
gested, because the gastric juice acts by contact, and, the 
smaller the particles, the greater the effect of the gastric 
juice. No claims are made by the manufacturers for its 
solubility, but for its ease of digestion and its nutritive 
value. 

The directions for preparing it for an infant six months 
of age are to take: — 

2y 2 tablespoonfuls of food. 

1 pint of hot water. 

1 pint of rich cows' milk. 



PROPRIETARY IXFAXT-FOODS. 215 

VThen prepared as above, using rich cows' milk, con- 
taining about 6 per cent, of fat, their analysis shows that 
it contains: — 

Eskay's Albumenized 

Food. Woman's Milk. 

Fat 2.96 2.41 

Proteids 2.55 2.35 

Carbohydrates 6.13 6.39 

Milk-sugar 5.07 

Insoluble carbohydrates 1.06 

Reaction alkaline. Reaction alkaline. 

MELEEx's FOOD. 

Mellin's food is a malted cereal food (Class B). This 
food is stated by its makers to be a soluble dry extract 
from wheat and malt, for the modification of fresh cows' 
milk. 

The carbohydrates therein are in the form of dextrin 
and maltose, and constitute about 80 per cent, of the food; 
the proteids amount to about 10 per cent., and are derived 
from the cereals. Mellin's food is almost completely sol- 
uble in water. It is especially noticeable that this food 
does not contain any starch. 

The directions for preparing this food for use for in- 
fants six months of age and over are to dissolve 2 heaping 
tablespoonfuls of food in */ 4 pint of hot water and 3 / 4 
pint of cows' milk. 

Composition when prepared as above: — 

Mellin's Food. 61 Woman's Milk. 

Water 88.00 88.51 

Salts 0.47 0.34 

Proteids 2.62 2.35 

Fat 2.89 2.41 

Maltose, dextrin, etc 2.73 

Milk-sugar 3.25 6.39 

Reaction alkaline. Reaction alkaline. 



61 According to Chittenden. 



216 



INFANT-FEEDING. 



In total solids this food differs but slightly from 
woman's milk, and in the various constituents its simili- 
tude to woman's milk is remarkably close. Of the car- 
bohydrates the maltose and dextrin are a little less in 
amount than the milk-sugar, and the total carbohydrates 
(5.98 per cent.) are only slightly less than the amount 
in woman's milk. 

The manufacturers of Mellin's food present many 
formulas for preparing the food for use to meet various 
indications. The following formulas are given with the 
analyses of the respective milk-modifications: — 



Formula and Analyses for Preparing Mellin's Food. 
For Infants about Two Months Old. 



Mellin's food, 6 teaspoon- 1 

fuls (level). Gives this 



Milk, 6y 2 fluidounces. 
Water, 9% fluidounces. 



composition: 



Water 93.40 

Salts 0.35 

Proteids 1.69 

Fat 1.53 

Carbohydrates (no 

starch) 3.03 



Mellin's food, 2 table- 
spoonfuls ( heaping ) . 

Cream, iy 2 tablespoon- 
fuls. 

Milk, 4 fluidounces. 

Water, 12 fluidounces. 



Low Proteids. 



Gives this 
composition: 



f Water 91.50 

Salts 0.37 

Proteids 1.45 

Fat 2.50 

Carbohydrates (no 
starch) 4.18 



High Fat and Low Proteids. 



Mellin's food, 3 table- 
spoonfuls (heaping.) 
Milk, 4 fluidounces. 
Cream, 2 tablespoonfuls. 
Water, 12 fluidounces. 



Gives this 
composition: 



Water 89.36 

Salts 0.45 

Proteids 1.65 

Fat 3.00 

Carbohydrates (no 

starch) 5.54 



PROPRIETARY INFANT-FOODS. 217 

PEPTOGENTC MILK-POWDER. 

This product is stated by its makers to be an article 
containing milk-sugar and a digestive ferment capable of 
acting on casein, offered for the preparation of an arti- 
ficial infant-food. McGill states: "It is not, in the strict 
sense, a food. Its professed object is so to change the 
composition of cows' milk as to render this comparable 
to human milk. This it seeks to do by introdncing milk- 
sugar and small quantities of albuminoids." According 
to McGill's analysis, it is composed almost entirely of 
milk-sugar (96.60 per cent.). 

The following analysis is by Leeds, and is taken from 
a circular of the makers. 

Composition of "humanized milk" prepared as di- 
rected, using 4 measures of peptogenic milk-powder with 
1 / 2 pint of milk, 1 / 2 pint of water, and 4 tablespoonfuls 

of cream: — 

Humanized Milk. Woman's Milk. 

Water 86.20 88.51 

Ash 0.30 0.34 

Proteids 2.00 2.35 

Fat 4.50 2.41 

Milk-sugar 7.00 6.39 

Reaction alkaline. Reaction alkaline. 

Chittenden's analysis of this "humanized milk" is al- 
most identical with the above. 

The proteids of the cows' milk undergo a change in 
the peptonizing process, being converted chiefly into par- 
tial peptones, and in this form they cannot be said to re- 
semble the proteids of woman's milk, which have not been 
acted upon by a proteolytic ferment. 



CHAPTEE XXXII. 

Professor Gaertner Mother-milk. 

Several years ago the author was persuaded to use 
Gaertner milk on a series of cases. The milk was sold 
in tin cans. The manufacturers would not take the ad- 
vice given them : to use fresh milk and deliver the milk 
in clean bottles daily. The author feels sorry to state 
that such food as "milk sealed in tin cans" cannot be 
recommended for healthy, and certainly not for sick, in- 
fants. 

In a paper entitled "The Clinical Value and Chem- 
ical Results" the author published a paper in the Med- 
ical Record, December 11, 1897. This new food has now 
been used about five years in Europe, and is the outcome 
of the scientific endeavors of Professor Gaertner, of the 
University of Vienna. The first paper was published by 
Gaertner in the Therapeutische Wochensclirift, May 5, 
1895. 

A few months before, January, 1895, Gaertner, in 
an address before the Vienna Scientific Society, explained 
the mode of preparation and the results obtained with 
his new modification of cows' milk, for such the mother- 
milk of Gaertner really is. Professor Gaertner, in the 
preparation of his food, has aimed to overcome what has 
been the great difficulty in infant-feeding — namely: to 
reduce the excess of casein by a scientific process without 
the addition of chemicals. 

To achieve this result he employs a machine called a 
separator or Pfannhaiiser centrifuge, which makes four 
thousand or eight thousand revolutions per minute. The 
apparatus consists essentially of a drum of steel, which 
revolves on its axis. This drum is filled with equal parts 
(218) 



GAERTNER MOTHER-MILK. 



219 



of fresh cows' milk and sterilized water. The mixture 
contains approximately the same amount of casein as hu- 
man milk, for cows' milk undiluted contains about twice as 
much casein as human milk. The mixture is next poured 
into the centrifuge and the speed of the drum is carefully 
regulated, so as to separate the mixture contained therein 
into (1) a creamy (fatty) milk and (2) a skimmed milk. 
The two portions so separated are then led off separately 
by suitable openings in the centrifuge. 

The analysis of each of these portions shows that the 
creamy milk has the same quantity of fat as is found in 
human milk, while about 2 per cent, of the casein is con- 
tained in the skim-milk, and the remainder, about 1.7 per 
cent., remains in the creamy milk. The chemical com- 
position of fat milk is shown in the following table: — 

Proteid. Fat. Sugar. Ash. 

Fat milk 1.76 3-3.5 2.5 0.35 

Human milk 1.03 3.5 7.03 0.21 

Cows' milk diluted with one- 
half water 1.76 1.6 2.5 0.35 

If, now, 3 or 4 grammes of milk-sugar be added to 
every 100 cubic centimetres of fat milk, the percentage 
of sugar is brought up to the level of sugar in human 
milk. This addition is made before sterilizing. The fat 
milk has the advantage over the diluted milk of having 
"a higher percentage of fat"; it also curdles more slowly 
than diluted milk and the curd forms a more nocculent 
precipitate. 

According to Escherich, the following amounts should 
be used at different ages of infancy, feeding every two to 
four hours: — 



Infants under 2 weeks 
Infants 3 to 4 weeks . 
Infants 4 to 8 weeks . 
Infants 3 to 4 months 
Infants 5 to 6 months 



500 c.cms. 

750 c.cms. 
1,000 c.cms. 
1,250 c.cms. 
1,500 c.cms. 



(17% I) in 9 feedings. 

(26 I) in 8 feedings. 

(35 §) in 8 feedings. 

(42 §) in 8 feedings. 

(50 3) in 7 feedings. 



220 INFANT-FEEDTXG. 

Escherich gives in detail his experience in feeding 
with fat milk fifty infants in a hospital, including rickety 
and tuberculous children. He has certainly met with 
marked success. Some cases have been under observation 
for six months. His article is published in extenso in 
Mitteilungen des Vereins der Aerzte in Steiermarh, No. 
1, 1895. ' 

Baginsky 62 mentions Gaertner milk as a new form 
of food introduced. In our country Jacobi 63 states that 
Gaertner milk is applicable to the majority of infants who 
require cows' milk appropriately prepared. 

A few years ago. I proposed to test the efficacy of 
Gaertner milk. With this in view I subjected the milk 
to a very rigid test, inasmuch as the time chosen, from 
June to October, was the heated term, which is the worst 
for milk digestion, and the hygienic conditions of the 
infants were those found in the average tenement-house, 
too well known to need description. 

The guides for ascertaining the degree of assimilation 
were the following factors: — 

1. The child's general condition, as manifested by its 
appearance, appetite, and sleep. 

2. The presence or absence of gastro-enteric disturb- 
ances, such as vomiting, colic, restlessness. 

3. The condition of the stools, constipation or diar- 
rhoea, the number of stools in twenty-four hours. 

4. The gain in weight; weekly observations. 

The nurses or mothers were instructed to note the 
amount of food taken and the number of stools in twenty- 
four hours. 

We submitted the stools passed in twenty-four hours 
to Mr. Herman Poole, our chemist, whose chemical re- 

62 "Lehrbuch der Kinderkrankheiten," fifth edition, pages 35 
and 36. 

63 "Therapeutics of Infancy and Childhood," page 508. 



BACKHAUS's MILK. 221 

port is of interest. 64 We tried to ascertain how much 
proteids, fat, sugar, and salts were taken, how much 
absorbed, and how much was voided in the fasces with- 
out having taken part in metabolism. 

Backhaus's Milk. 65 

The following method is employed in the production 
of this food. The milk from different breeds of cows is 
mixed and passed through a centrifuge, to separate the 
cream from the milk and to remove any impurities that 
might have gained access to the milk, notwithstanding 
the great care used in handling. Three grades are pro- 
duced: two for infants, the third representing full milk 
in its composition. After separating it from the cream 
the milk is exposed to the action of a mixture of rennet, 
trypsin, and sodium carbonate, which are combined in 
such proportions that the trypsin will have converted at 
the end of thirty minutes 30 per cent, of the casein into 
soluble albumin. By this time the action of the rennet 
coagulates the balance of the casein and thus arrests the 
action of the trypsin. The temperature of the mixture 
is now raised to 80° C. (176° F.) by the introduction of 
steam into it. At this temperature it is kept for five 
minutes. At the end of this time it is strained through 
cloths and mixed with half its volume of water, one- 
fourth its volume of cream, and the necessary amount of 
sugar of milk. It is finally put up in bottles holding 125 
grammes (about 4 ounces) and sterilized. 

The second grade, for older children, is obtained by 
mixing equal parts of milk and water with half the quan- 
tity of cream and with milk-sugar. This is put up in 
quantities of 200 grammes (about 6 1 / 2 ounces). 



64 Those interested are referred to my paper, entitled "Gaertner 
Milk," containing an elaborate chemical report by Professor Poole: 
New York Medical Record, December 11, 1897. 

65 Archiv fur Kinderheilkunde, B. 26, H. 5 and 6. 



222 INFANT-FEEDING. 

The third grade, in bottles holding 300 grammes 
(about 10 ounces), represents cows' milk in composition, 
modified by the above-mentioned process. The composi- 
tion of the three grades is given as follows: — ■ 

Fat 3.1 3.2 3.3 

Sugar of milk CO 5.4 4.8 

Casein 0.6 1.8 3.0 

Albumin 1.0 0.3 0.5 

Ash 0.4 0.4 0.7 

The milk has been tried at the Wiener allgemeine 
Poliklinik by Frlihwald in a series of twenty cases, the 
histories of which are given by the author. With the ex- 
ception of six, these children have been under observation 
for more than two months. When first seen the children 
were all suffering from different forms of digestive dis- 
turbances, and from malnutrition; some were suffering 
from severe marasmus, and most of them passed through 
some other disease while they were under observation. 
Three of the infants took the breast in addition to the 
Backhaus milk for periods of two and three weeks, when 
they, too, had to be put on the artificial milk entirely. 
The children took about six bottles of Xo. 1 up to four 
weeks, seven to eight to the end of the second month. 
From the middle of the third month the second degree 
was gradually substituted, while Xo. 3 was used only in 
the case of an older child. A daily gain was observed 
of from 18 to 30 grammes (about 1 / 2 to 1 ounce). In 
private practice and in healthy children a gain of 50 
grammes (about 1 1 / 2 ounces) not rarely happens. The 
milk keeps well. 

LahmaeVs Ye get able-milk. 

In Europe, and recently also in our country, the feed- 
ing of infants has been enriched with a new product; 
thus, Dr. Lahmann believes that the great panacea is 
feeding infants with milk which he designates as "vege- 



lahmann's vegetable-milk. 223 

table-milk." It resembles a thick jelly, and is made by 
Hewwel & Veithen,. Cologne. His theory consists, in 
brief, in substituting nuts and almonds, which are rich 
in albumin and fat, instead of cereals to dilute milk, his 
idea being that an emulsion, which is digestible and sup- 
posed to be rich in albumin, is doubtless better than pure 
water or a thin starch-paste. In order to add food-salts, 
which are not supplied by this means, he extracted them 
from leaf vegetables, which are rich in food-salts, and 
added some sugar-syrup. In this manner he claims to 
have made a preparation which he states is chemically 
equal to human milk, and full of nutritive value. His 
idea is that the interposition of plant-albumin (conglutin) 
particles, which coagulate with difficulty between the 
coagulating casein masses, would increase their digesti- 
bility by breaking them up, and that the digestion of the 
plant-albumin and oil, as well as of the sugar and food- 
salts, would present no difficulty. 

Stutzer, of the University of Bonn, reports thus: 
The vegetable-milk is distinguished from children's food 
by the absence of starchy substances. In common with 
Biedert's cream-mixture, the vegetable-milk contains con- 
siderable quantities of fat in an emulsified condition. It 
differs from the cream-mixture in the way it is prepared, 
and in its other qualities. 

Chemical Analysis. 

Fat 34.72 per cent. 

Plant-casein and similar nitrogenous con- 
stituents 12.00 per cent. 

Sugar and plant-dextrin 31.02 per cent. 

Salts 1.64 per cent. 

Water 20.62 per cent. 

My own personal experience has been rather favor- 
able with the use of the vegetable-milk, inasmuch as an 
emulsion of almonds and nuts was used to dilute the curd 
of cows' milk. Thus, equal parts of vegetable-milk with 



224 INFANT-FEEDING. 

cows' milk were taken by an infant for several months, 
and it was very well assimilated. Not only did the child 
gain in weight, but the bowels were in a fair condition, 
and the infant remained strong. My experience, how- 
ever, is too limited as yet to give a positive opinion. 

Condensed Milk or Condensed Cream. 

Hundreds of infants are fed with condensed milk. 
This has its reason: — 

First. The readiness with which condensed milk is 
obtained. 

Second. The great cheapness of this article. 

Third. The ease with which the feeding-mixture can 
be prepared. 

Jacobi says that some manufacturers use pure cows' 
milk ; others find it in accordance with the health of their 
bank-accounts to nse skimmed milk. 

Quantity of Sugar in Condensed Milk. — Milk sold in 
onr city for immediate use contains about 12 to 15 per 
cent, of sugar. Milk to be kept for an indefinite time 
contains as much as 50 per cent, of sugar. These varia- 
tions show how serious it is to use the same quantity 
of condensed milk all the time and from different 
sources with such an enormous variation in the quantity 
of sugar. 

Kehrer — quoted by Jacobi — states, regarding it, that 
it increases the formation of lactic acid. Fleischman 
states that it gives rise to thrush, and diarrhoea; Daly, 
that it fattens them (?), but gives rise to rachitis. 

The worst specimens of rachitis and spinal rickets are 
seen in my clinic in condensed-milk babies. Our medical 
literature reports many cases of apparent health in infants 
fed on condensed milk. It has led Dessau, with a large 
experience with infants, to mention such a method, al- 



CONDENSED MILK OR CONDENSED CREAM. 225 

though, he advocates cows' milk, properly modified, for 
continued use. 66 

In traveling, when good fresh cows' milk cannot be 
obtained, then I permit the use of condensed milk, but 
for a few days or for a week only, as on the ocean steamer, 
where cows' milk cannot be had. 

My experience among hundreds of children seen in 
my Children's Service at the German Poliklinik and also 
at the service at the West-Side German Dispensary dur- 
ing these last ten years has been that children so fed have 
rickets; that they are predisposed to the infectious dis- 
orders; that they have less resistance and far less vitality, 
especially in combating such diseases as pneumonia or 
diphtheria; that they have tendencies to hernias and de- 
formities, owing to the softer condition of their muscles 
and bones; that they invariably suffer with constipation, 
alternating with diarrhoea ; that their dentition is delayed, 
compared with other methods of hand-feeding. Thus 
summing it up, I cannot approve of this method at all. 

Condensed cream will be lauded by the mother whose 
baby is well, and again the same food will be con- 
demned by the mother of an infant whose rickety head, 
bones, and muscles are founded on an impoverished diet 
of condensed milk. We can account for the rickety child, 
but we cannot account for the healthy one on the same 
food. 

The directions on the tin of the Anglo-Swiss Con- 
densed Milk Company's Milkmaid Brand of condensed 
milk are, for newborn infants, add 14 parts of water; 
as the child grows older, gradually use less water, but 
never less than 7 parts. 

The analyses of all these condensed milks are of the 
milk diluted with both 7 parts and 14 parts of water — 
the two extremes. 



GG See my paper on infant-feeding (read before the Society for 
Medical Progress, April 11, 1896), published in extenso in Pediatrics 
for July 15, 1896. 

15 



226 INFANT-FEEDING. 

Gail-Borden Eagle 
Milkmaid Brand. Brand. 

With 7 Parts With 14 Parts With 7 Parts With 14 Parts 
Water. Water. Water. Water. 

Water 88.18 93.59 89.10 94.09 

Ash 0.36 0.19 0.29 0.16 

Proteids 1.50 0.82 1.31 0.71 

Fat 1.70 0.92 1.18 0.04 

Cane-sugar 6.00 3.25 6.59 3.57 

Milk-sugar 2.26 1.23 1.53 0.83 

Nestle's Swiss Milk. 

With 7 Parts With 14 Parts Woman's Milk 

Water. Water. " Oman S .UllK. 

Water 87.95 93.46 88.51 

Ash 0.25 0.14 0.34 

Proteids 1.51 0.82 2.35 

Fat 2.14 1.16 2.41 

Cane-sugar 5.81 3.15 

Milk-sugar 2.34 1.27 6.39 

The foregoing brands of condensed milks are consid- 
ered to be among the best npon the market. 

Cocoa. 

Dr. H. Cohn, 67 in describing the chemical value of 
cocoa as nourishment, states his belief that it is over- 
rated, and denies the value of the same. He bases his 
statement on the poor method of assimilation, owing to 
the large quantity of fat which could be removed by 
chemical process. Cocoa also contains 5.5 per cent, of 
tannic acid. Besides, the albuminoids are converted, by 
the process of roasting, into a very indigestible product. 
About the tannic acid, he says that it precipitates the 
digestive ferments, and unites with the albuminoids into 
insoluble compounds, causing the constipating factor. 
According to his experiments, only one-half of the 16.6 
per cent, of the albuminoids are absorbed, and, in order 
to give the human body enough cocoa to have a sufficient 
quantity of proteids, it would be necessary to feed at least 



Zeitschrift fur physiologische Chernie, xx, 1, 2. 



CHOCOLATE, ICE-CREAM, AND WATER-ICES. 227 

somewhat over 2 pounds daily, provided cocoa alone was 
given for nourishment. 

Chocolate. 

Chocolate contains about 45 per cent, of cane-sugar, 
but no dextrose or lasvulose. The remainder consists of 
cocoa-powder. Invert-sugar, or a mixture of glucose and 
albumin, is largely used in the preparation of uncrystal- 
lized sweets, such as the creamy matter in the interior of 
chocolate drops. The coloring of sw T eets is derived either 
from burnt sugar or from one of the aniline dyes, most 
commonly eosin. Cochineal is also a favorite colorer. It 
is interesting to know that these dyes may be excreted 
in the urine almost unchanged, and cases are on record 
where patients were supposed to be passing blood when 
they had merely been sucking red sweets. There is no 
reason to suppose, however, that such substances are harm- 
ful to life. 68 When there is a tendency to loose bowels, 
especially after the second summer, cocoa and chocolate 
should be added to the dietary. It is to be added to milk 
and thoroughly boiled. One cocoa feeding per day is 
usually enough. One teaspoonful of cocoa to a cup of 
milk, the latter to be thoroughly boiled, is the usual quan- 
tity used. Several formulae for making chocolate will be 
found in the "Dietary." 

ICE-CREAM AND WATER-ICES. 

Ice-cream and water-ices are very grateful to a fever- 
ish child. When milk and cream are refused they will 
be greedily taken. These preparations will alleviate the 
pain on swallowing in the case of diphtheria. They 
contain considerable nourishment, but must be given in 
moderation. Nausea and vomiting may frequently be 
controlled by them. 

6S Hutchison, "Food and Dietetics/' page 265. 



CHAPTEE XXXIII. 

Milk Idiosyncrasies in Children. 

Some children will not tolerate milk; physicians fre- 
quently report an intolerance of milk or its dilutions in 
children. This condition has long been known among 
adults. We frequently hear the latter say that milk makes 
them bilious, that it is not tolerated, and that they feel 
uncomfortable after a milk diet. "While this condition 
is of much rarer occurrence in children, certain cases are 
met in which milk is not tolerated. It has been the milk 
itself or the component parts of the same that has dis- 
agreed in certain children under the treatment of the 
writer. Breast-milk and several changes of wet-nurses 
gave the same distressing symptoms. Cows' milk was 
not tolerated, and was discontinued after various dilutions 
had been tried. 

The following case will serve to illustrate what is 
meant by the above condition: — 

Case I. — An infant, M. L., was born in July, 1901. The weight 
at birth was about 6 pounds. The mother had no milk, so a wet- 
nurse was secured. The infant was thus nursed for the next three 
months. The child gained about 8 ounces per week during the 
month of July, but in August and September it did not thrive. 

History of food after weaning: When the child was weaned, 
in October, it was given condensed milk, 1 drachm, to 12 drachms 
of sterile water, to which 1 drachm of lime-water was added. The 
child vomited and had eructations, although it had from one to two 
yellowish stools per day. When this child was weaned it was al- 
ways constipated and required an enema of plain water to relieve 
the bowel. The stools during the summer months contained a 
great deal of mucus, which was shredded and yellowish green in 
color. The infant was colicky; the stools had a very sour smell; 
the child frequently had an explosive vomit. The condensed milk 
was continued through the month of October, and, as the child did 
not seem to thrive, it was given Just's food. This the child re- 

(228) 



MILK IDIOSYNCRASIES IX CHILDREN. 229 

fused, so Xestle's food was substituted and seemed to agree. When 
milk was added the child vomited a sour-smelling liquid, and later 
on refused the Xestle's food. As there was constant anorexia, 
the child was next fed with Ridge's food. As this was not very 
well borne, a trial was made of Allenbury's food. When this dis- 
agreed, the child was placed on Eskay's albumenized food. This 
also was not tolerated, and the child was given some strengthening 
meal. This was not borne any better. 

Examination: On Xovember 24th the child weighed about 9 
pounds. It had lost 8 ounces the week previous to its parents 
consulting me. This loss of weight disturbed the family and caused 
them to seek a change of diet. The examination of the child 
showed some very interesting facts. First, the general appearance 
of the child was one of an undersized, undeveloped, markedly ra- 
chitic baby; there were beaded ribs; the ends of the long bones — 
particularly the radius, ulna, and femur — were markedly rachitic. 
Subluxation of the knee-joints was present. The head of the child 
was very rachitic: the fontanelle was very widely open; in fact, 
the fontanelle was three times the size of that of a normal baby. 
The extremities were extremely cold: the circulation was very 
poor: the action of the heart was very feeble; a blowing murmur 
was distinctly heard at the apex and could also be heard in the 
vessels of the neck. It was a distinct haemic murmur, and was 
attributed to the profound anaemic condition which was found to 
exist. 

The trained nurse in charge of the case had been with the baby 
since birth and had stated that the child had had a series of 
spasms which were not only regular, clonic, and tonic contractions, 
but they occurred once every twenty-four hours at a certain time 
of the day. The child was very fretful, very nervous, constantly 
irritable, and had had very restless spells at night, which disturbed 
its sleep. There was a slight eruption around the anus; the 
child had difficulty in taking the nipples as well as nursing at the 
breast. 

An examination of the throat showed congenital adenoid vege- 
tations. This latter condition interfered with the child's proper 
feeding: it prevented the child from properly taking its food and 
breathing at the same time. It would take the nipple or the 
breast and then let go, in order to breathe. Spoon feeding was 
resorted to when the child would not take food from its bottle. 
Attention was directed to the rhino-pharynx. By gradual cauter- 
ization the child's condition was so markedly improved that its 
general condition, with the appetite, stools, sleep, and weight, all 
assumed normal tendencies. 



230 INFANT-FEEDING. 

Dietetic treatment: The child was given the following: — 

IJ Whey . . . . 2 ounces. 

Milk 2*/ 2 ounces. 

Peptogenic powder .... % measure of the metal cap. 

Granulated sugar % teaspoonful. 

Mix the above and peptonize the milk by a slow process for 
about ten minutes, and when cooled to the proper feeding tempera- 
ture feed the above quantity every three hours. 

The child took the bottle very well; in fact, took 4 ounces, re- 
tained the food, and seemed to like it. The following are the 
nurse's reports: — 

"November 24th, 10.30 p.m., took 4 ounces; has not vomited; 
seems to like food." 

"November 25th, 4 a.m., took 4% ounces of food; retained, 
at 7 a.m. took nearly 4 ounces; retained. At 11 a.m. child crying 
and abdomen distended; child appears colicky." 

A warm enema consisting of 2 pints of chamomile-tea was 
ordered; so that the colon and rectum were thoroughly flushed. 
The child was instantly relieved after some cheesy curds and mucus, 
plus faeces, were washed away. These fermentative conditions — 
resulting in gaseous eructations; colicky, distended, tense abdomen, 
with crying and occasional cheesy, curdy stools, the temperature 
frequently reaching 101° to 103° F. in the rectum, occasional vomit- 
ing, and disturbed appetite — were invariably noticed when milk, 
peptonized or predigested or in any form, was given to this child. 

It was therefore apparent to me that this baby would not 
digest milk, and hence some other form of feeding was required. 
On December 17th a new form of feeding was commenced which 
is known as a modified form of malt-soup. A similar plan of feed- 
ing is used extensively abroad, at the foundling asylums which I 
visited; notably at the New Berlin Foundling Asylum, which is 
under the supervision of Dr. Finkeistein. This food is known as 
Keller's malt-soup. Its preparation is rather difficult unless per- 
formed by a competent chemist. This food has been used for many 
years in the nursling pavilion of the Kaiser and Kaiserin Friedrich 
Children's Hospital, under the direction of Professor Baginsky. I 
am indebted to the New York Walker-Gordon Laboratory for great 
care in the preparation of this food, which has certainly served 
me very well. The following formula was used in the beginning 
and was changed, as can be seen by studying the accompanying 
table: — 



MILK IDIOSYNCRASIES IN CHILDREN. 



231 



Food Ordered at Walker-Gordon Laboratory. 
(Delivered daily as ordered for Case 1.) 



Date. 



Dec. 17, 1901 



Dec. 20, 

Dec. 24, 

Jan. 4, 

Jan. 9, 

Jan. 12, 



1901 . 
1901. 

1902 . 
1902 . 
1902. 



Jan. 


21, 


1902 . 


Feb. 


7, 


1902. 


Feb. 


18, 


1902. 


Feb. 


22, 


1902. 



Mar. 1, 1902 
Mar. 3, 1902 



1902 
1902 



Mar. 6, 1902 . 

Mar. 10, 

Mar. 17, 

April 1, 
April 13, 
April 16, 
April 18, 
April 22, 
April 26, 
May 2, 



May 21, 
May 23, 



1902. 
1902 . 
1902 . 
1902. 
1902. 
1902. 
1902 . 

1902. 

1902 . 



No. OF 


Oz. 


Tubes. 


4 


3 


4 


3 


8 


3 


8 


3% 


8 


4 


5 


4 


8 


4 


4 


4 


4 


4 


8 


4 


4 


4% 


4 


5 


4 
4 


4}| 
4? 


4 


4 


4 


4 


5 


4 


5 


4 


5 


8 


6 


4 


6 


4 


6 


8 


6 


*6 


4 


8 
8 


4M 
4% 


8 


5 


8 


6 


8 


6 


4 


6 


§4 


6 


8 


6 



Dex. 

Wheat. 

Oz. 



1 

Same 
Same 
Same. 
Same. 
Same. 
Same. 
Same. 
Same 
2 



Milk. 
Oz. 



Water. 
Oz. 



Malt- 

EXT. 

Oz. 



11$ Pot. 

Bicarb. 

Sol. Drachms. 



5% 10 1% 

(but without wheat), 
(but with dextrinized wheat). 



1M 



$ 



2>| 



(but % oz. more milk to each tube) . 
15 16 

9% 

ii>| 

9>| 

log 

2 



3 

4 

3 

4 
20 
10 



2% 
3 
3 
3 



2% 



24 



14 
16 
16 
16 
24 
12 



24 



15% 

14)1 

14>| 

14>| 

26 

13 

15 

22 



21 

21 
21 
21 



24 



I 



I 

4/1 
1M 



3% 



2% 

iH 



ij| 
iM 
ig 
i*| 

3>| 
1% 
1% 
3>| 



2K 

21 4 

2M 
2i| 
252 



*Each tube of 4 ounces of distilled water and 3 drachms of Nestle's food. 
fBarley-water. JDistilled water. 
§1% ounce s of Nestle's, % ounce of malt-extract, and 24 ounces of distilled water. 

(Case II.) 



Date. 
1902. 


No. 


Oz. 


Dex. 

Wheat. 
Oz. 


Wh. 

Milk. 

Oz. 


DlST. 

Water. 
Oz. 


Barley 

Jelly. 

Oz. 


Malt- 
ext. 
Oz. 


11 56 Pot. 

Bicarb. 

Sol. Drachms. 


May 28 . . 
May 29 . . 
May 30 . . 
May 31 . . 
June 2 . . 
June 5 . . 


7 

7 

7 

10 

7 
7 


6 
6 

7% 
7>| 


1 

1% 


14 

g % 

52 
35 
35 


28 

17% 

14 

21 

14 

14 


* «k' 

5M 
3% 
4 


3 

2 
2 
3 
2 


3% 
4| 

3% 
5M 

3% 
3% 



Keller's Malt-soup. 

Take of wheat-flour 2 ounces and add to it 11 ounces of milk. 
Soak the flour thoroughly and rub it through a sieve or strainer. 



232 INFANT-FEEDING. 

Put into a second dish 20 ounces of water, to which add 3 ounces 
of malt-extract; dissolve the above at a temperature of about 
120° F. and then add 2 1 / 2 drachms of 11-per-cent. potassium-bicar- 
bonate solution. Finally, mix all of the above ingredients and boil. 
This gives a food containing: albuminoids, 2 per cent.; fat, 1.2 
per cent.; carbohydrates, 12.1 per cent. There are in this mixture 
0.9 per cent, of vegetable proteids. 

The wheat-flour is necessary, as otherwise the malt-soup would 
have a diarrhceal tendency. The alkali is added to neutralize the 
large amount of acid generated in sick children. Biedert emphasizes 
the importance of giving fat, rather than reducing its quantity, in 
poorly nourished children, and cites the assimilability of his cream- 
mixture or of breast-milk in underfed children as proof of his as- 
sertions. The author has used this malt-soup most successfully in 
the treatment of athrepsia (marasmus) cases, in which the children 
were simply starved. 

On studying the ingredients one can easily see that the malt- 
extract and the dextrinized wheat are the highly nutritious agents. 
We know that dextrinized wheat is very well absorbed by some 
of the youngest infants. The addition of the potassium bicarbonate 
served to render the food markedly alkaline, which is an extremely 
important thing. When milk was added with the object of in- 
creasing the percentage of fat and proteid, we deviated from the 
quantity as originally recommended by Keller. Colic and gastro- 
enteric fermentation were invariably encountered. A study of the 
accompanying weight-chart is extremely interesting. 

Case II. — The child, S. X., born of healthy parents, was put 
to the breast on the second day after birth. On the third day 
after birth there was a profuse flow of milk. The infant appeared 
quite well satisfied after nursing. 

The child was nursed every two hours; was changed from the 
right to the left breast at every other feeding. Fifteen to twenty 
minutes after each nursing there were symptoms of restlessness 
and constant crying. The legs were flexed on the abdomen: there 
were eructations and all the evidences of colic. The child cried at 
least one hour, until it fell asleep from exhaustion. This state 
of affairs continued each day for at least two weeks. A speci- 
men of breast-milk was examined by a chemist and was found to 
be perfectly normal in its elements and in their relative per- 
centages. 

The family was greatly distressed at ifs continued crying and 
apparently colicky condition, but was surprised, in spite of this 
condition, to find that the infant gained between 4 and 6 ounces. 
It was necessary to give 1- to 2-grain doses of chloral hydrate at 



MILK IDIOSYNCRASIES IN CHILDREN. 



233 




234 INFANT-FEEDING. 

night to procure sleep. We finally decided to change the mother's 
milk and to substitute a wet-nurse. The child behaved just as 
badly with the wet-nurse; had the same crying spells shortly after 
nursing, which continued frequently for one hour. When the breast 
was discontinued for one day and barley-water or albumin-water 
substituted, the child would appear comfortable, and not have the 
pains which we noted while feeding breast-milk. An interesting 
point is the fact that all infants having the milk idiosyncrasy had 
elevated temperatures, ranging from 101° to 102° F. continuously. 
The stool was filled with large, cheesy, curdy masses. To aid 
the assimilation of the milk, small doses of pancreatin and bi- 
carbonate of soda were given; with the idea of slightly peptoniz- 
ing the milk, essence of caroid, 1 / 2 teaspoonful before each feeding, 
was also prescribed. In addition thereto small quantities of es- 
sence of pepsin and hydrochloric acid were given after each feeding, 
to aid the digestion of this food. Neither of these medications 
relieved the condition, and I finally decided that breast-milk was 
not adapted for this child. We next resorted to very diluted cows' 
milk, using 1 part of milk with 3 parts of oatmeal-water. We 
gradually increased the strength until y 2 milk and y 2 oatmeal- 
water was given. Milk, however, in any form, whether diluted or 
pure, was poorly borne. When cereal decoctions were substituted, 
they were invariably better tolerated. The same was true when 
soups and broths were given. The latter were always well borne, 
and the moment milk was added, no matter in what form, trouble 
was immediately encountered. 

Case III. — Another baby, an equally instructive case, was 
brought to my office by Dr. Hecht, of West Hoboken, N. J. It 
could not assimilate milk in any form. This child not only had 
dyspeptic and colicky symptoms, with flatulence and cheesy stools, 
but also evidences of fermentation in the bowel, and invariably 
had acute febrile attacks with temperature ranging from 101° to 
103° F. whenever milk was fed. This gastric disturbance was only 
apparent after milk-feeding. The child behaved well when sub- 
stitute feeding other than milk was given. Almond-milk was one 
of a series of foods given which was not only well borne, but was 
well adapted for nourishing when milk was not tolerated. 

It was found wise, if 4 ounces of milk had been previously 
given, to substitute at the next feeding 4 ounces of barley-water or 
oatmeal-water, and to feed 4 ounces at regular intervals of three or 
four hours each. 

Almond-milk can be given in the same quantity and at the 
same intervals as breast-milk. It must be sweetened by adding 
1 teaspoonful of sugar to each 4 ounces of food. Delicate infants 



MILK IDIOSYNCRASIES IN" CHILDREN". 235 

require 2 ounces — repeated every two or three hours. If this 
quantity is well borne by the stomach, then 1 ounce more can be 
added every two days. Almond-milk contains vegetable proteids 
and is exceedingly valuable as a milk-diluent. It serves well in- 
stead of barley-, rice-, or oatmeal- water if it is sweetened with 
cane-sugar. 



CHAPTEE XXXIV. 

Laboratory Modification of Milk. 

It is now several years since a Walker-Gordon milk- 
laboratory was established in Xew York. Their method 
of feeding infants is based on mixing the ingredients in 
such combination that, when combined, they should re- 
semble certain chemical formulae of breast-milk at various 
ages. Blanks are given the physician, which are filled out 
according to the individual requirement. The age and 
weight are noted. Fat, sugar, proteid, and water are pre- 
scribed in percentages. We are therefore able to state 
that the food ordered contains a definite percentage of 
fat, sugar, caseinogen, and lactalbumin. The same is also 
true regarding the heating of food. We can prescribe 
the food sterilized, pasteurized, or raw. A great many 
changes can be made. We can increase or decrease the 
fat; the same is true of sugar and proteids. 

My advice to those using modified milk is to begin 
with low proteids. An infant at birth, if deprived of 
breast-milk, should never receive more than 0.50 per cent, 
of proteids, in the beginning of laboratory feeding. Some 
infants do very well on 0.25 per cent, of proteids soon 
after birth. It is a simple matter to note the infant's 
condition, its stools, its sleep, and its weight. 

If the above-named conditions are satisfactory, then 
we can increase the proteids, the fat, and the sugar. Xote 
conditions every day, and have the mother or nurse in 
charge of the infant report the slightest disturbance. 
Vomiting, if present, its frequency and character, should 
be carefully noted. So also should colicky symptoms, 
eructations, flatulence, and greenish, curded stools. 

Constant crying, disturbed sleep, and restlessness are 
all factors that need correction and supervision. 
(236) 



LABORATORY MILK. 237 

The quantity of food prescribed, depends upon the 
requirements of each child. Some children can take 3 
ounces at one feeding while others appear satisfied after 
taking 2 ounces of food. 

Examples. — For a child at birth. 

Fat 2.00 

Sugar 5.00 

Proteids 0.50 

Lime-water 5.00 



Formula I. 



Or:— 



Fat 2.00 

Sugar 5.00 

Proteids 0.75 

Lime-water 5.00 



Formula la. 



Milk, raw, pasteurized, or sterilized. 

Quantity of food to be given, 2 ounces every two 
hours. 

My preference for food prescribed at a laboratory 
where germ-free milk is obtainable is to prescribe it raw. 
"When constipation is encountered the raw milk will mod- 
ify such conditions. 

If diarrhoea or looseness exist, then my preference is 
to use heated milk: sterilized about ten to twenty minutes. 

If the infant thrives, the ingredients can be increased ; 
also the quantity at each feeding: — 

Fat 2.50 ^j 

Su S ar 6 - 00 I Formula II. 

Proteids 1.00 [ 

Lime-water 5.00 J 

Still later, if conditions warrant it: — 
Fat 3.00 

Su ^ ar 6 - 00 : 

Proteids 1.50 

Lime-water 5.00 



238 INFANT-FEEDING. 

In this manner we can gradually increase the per- 
centage of ingredients until whole milk is ordered. 

When abnormal conditions prevail, — such as loose 
bowels, — then barley-water can be substituted for the 
sterile water. 

The following formula was recently prescribed at the 
laboratory for a child, 1 year old, with very loose bow- 
els: — 



Whole milk 15 ounces 

Rice-water 14 ounces 

Dextrinized wheat 1 ounce 

Dry cane-sugar 1% ounces 

Cornstarch 2 teaspoonfuls 



Formula IV. 



To be thoroughly mixed, sterilized 20 minutes, and 
divided into five feedings, each bottle containing 6 ounces. 

When the bowels acted better, and had a more solid 
consistency, I added malt-extract, 1 / 2 teaspoonful to each 
bottle. When improvement was noted the above formula 
was changed to: — 

Whole milk 28 ounces 

Barley-water 20 ounces 

Cornstarch 1 ounce ► Formula V. 

Dry sugar 6 drachms 

Dextrinized wheat 2% ounces 

Sterilize, divide into eight bottles of 6 ounces each. 

The following case illustrates successful modified-milk 
feeding with milk prepared at Walker-Gordon labora- 
tory : — 

Baby A, 4 months old, was seen by me September 19, 1901, with 
the following history: It was the first baby, forceps delivery, 
podalic presentation; weight at birth, about 6 pounds. Family his- 
tory excellent. Nursed at mother's breast about four weeks, but, 
owing to a scanty flow of milk, she required additional hand-feeding. 
The baby received milk and barley-water, sterilized or boiled. A 
bottle was given after each nursing (so-called mixed feeding). 

Result: Constipation; relief given by soap-suds enema. This 
condition lasted about six weeks. The child had colic of a very 
severe form and also tenesmus: i.e., constant straining. 



LABORATORY MILK. 239 

Child was weaned of the mother's breast; food ordered was: — 

Milk 8 ounces. 

Barley-water 16 ounces. 

Milk-sugar 3 teaspoonfuls. 

Lime-water 2 teaspoonfuls. 

Salt 10 grains (pinch) . 

Sterilize thirty minutes, divide into eight feedings, and feed 
every two hours. 

When about 2 months old, child had greenish, spinach-like, very 
slimy stools, also containing white curds. The infant appeared 
hungry or thirsty all the time, was restless, had insomnia, and suf- 
fered with colic. There was no vomiting. A physician ordered 
the milk discontinued and barley-water given instead. The child 
became extremely emaciated; hence was removed to the sea-shore. 
At the sea-shore Dr. J. ordered: — 

Milk 1 ounce. 

Boiled water 3 ounces. 

Milk-sugar and salt. 

This food was quite well tolerated. When oatmeal-water was 
given instead of barley-water, to offset the constipating effect, a 
miliary eruption appeared. 

During the second week of September the child still had diar- 
rhoea. Stools still greenish, containing mucus and shreds. The 
rectum prolapsed from constant tenesmus. Cereal milk was tried, 
but with no success. 

The above is the clinical history given to me by the mother of 
the infant. 

Present condition: A very frail-looking infant, rather emaci- 
ated. Poor circulation, cold extremities, pallor of skin, anus 
slightly excoriated., and naevus on right side of thorax. 

Temperature normal in rectum, 98 i / s ° F.; pulse, 120; respira- 
tion, 28. Throat normal, tongue moist and has grayish-white, fur- 
like coating. Heart-sounds feeble; slight bronchitis, diffuse sonor- 
ous and sibilant rales heard on both sides of the chest. Stomach 
very markedly distended. Abdomen tympanitic on percussion. 
Colon distended. Liver enlarged. Spleen not palpable. 

Diagnosis: Chronic dyspepsia, atrophy due to mal-assimilation 
of food., and rickets. 

Prognosis: Fair. 



2-iO 



INFANT-FEEDING. 



Weight. 



September 


iy. 

25... . 


8 
. . 


lb. 

lb. 


15 02 

12 " 


Gained 








13 " 


October 


2 


. . 10 


lb. 


2 " 


Gained 








6 " 


October 


9 


10 


lb. 


" 


Gained 








7 " 


October 


10 


. . 11 


lb. 


2 " 


Gained 








" 


October 


23. .. . 


. . 11 


lb. 


14 " 


Gained 








12 " 


October 


30. .. . 


. . 12 


lb. 


6 " 


Gained 








8 " 


November 


30. .. . 


.. 15 


lb. 


7 " 


With cl( 


)thes. 









A study of the weight-chart will prove very interesting. 

The dyspeptic and rachitic baby with cold extremities is to-day 
a beautiful child, well developed, and was not seen by the author 
for several months — until it was necessary to vaccinate. 

Ordered: Syr. rhei arom., 3j every four hours, to cleanse gastro- 
intestinal tract. Also: — 

I£ Strychnine sulphate 0.002 

Saccharin 0.06 

Decoction of cinchona (fiava) 60.0 

M. Teaspoonful after feeding three times per day. 
The above as a cardiac and vascular stimulant. 



Sept. 20th: Food ordered at Walker-Gordon laboratory: — 

Fat 2.50 

Sugar 6.00 

Proteids 1.50 

Lime-water V 16 

Seven feedings of 6 ounces each. Use raw milk. Feed every 
two and one-half hours. 

The following day the child slept from 8 p.m. till 4 a.m. — eight 
hours continuously. Had three pasty^ stools. Infant appeared satis- 
fied after bottle. It was then ordered (September 22d) : — 



LABORATORY MILK. 24.1 

Fat 3.0 

Sugar 6.0 

Proteids 2.0 

No alkalinity. 

Kaw milk. Seven feedings, 6 ounces in each. 
Feed every two and three-fourths hours. 

Child seemed much better satisfied after feeding; vomited once; 
had two stools, both of yellowish color, and of good consistency. 
One stool at 5 a.m. and one at 5 p.m. 

September 28th: — 

Fat 3.50 

Sugar 6.00 

Proteids 2.00 

Pasteurize the food. Six feedings of 6 ounces each. Feed every 
three hours. 

When bowels acted too frequently I pasteurized the food; not 
otherwise. 

October 6th ordered: Bran and sea-salt baths every second 
night; temperature of bath 95° F. ; followed by brisk rubbing to 
stimulate the circulation. The digestion of the infant being excel- 
lent, stools regular, the percentage of ingredients was increased: — 

Fat 4.00 

Sugar 6.00 

Proteids 2.50 

Use barley-jelly instead of water; alkalinity, 5 per cent. Heat 
to 167° F. 

Six feedings of 6 ounces each. 

Feed every three and one-half hours. 

Child is excellent, gaining in weight; sleeps well; stools normal; 
has no colic. Discontinued laboratory feeding. 

Home modification: — 

Pure raw cows' milk 30 ounces. 

Barley-water 18 " 

Peptogenic powder 3 teaspoonfuls. 

Divide into six bottles; warm each bottle before feeding. 

Feed every three and one-half hours. 

Add the barley-water to the raw milk and divide into six equal 
bottles, then place in refrigerator until feeding-time. At feeding- 
time empty a bottle into a clean saucepan, add the peptogenic, and 

16 



242 INFANT-FEEDING. 

warm to the temperature of 100° F. for ten minutes; then boil 
quickly for one minute and cool to feeding temperature. 

For the relief of constipation: — 

Infus. senna comp 2 ounces. 

Saccharin 1 grain. 

M. Teaspoonful every three hours until bowels move. 

Gradually abstracted one ounce of barley-water and added one 
ounce of pure milk, until after a few weeks the child received whole 
milk, sweetened with one teaspoonful of granulated sugar; 8 ounces 
every four hours. 

Also ordered six ounces of chicken-soup; steak-juice, gradually 
thickened with cereals; some egg-crackers, zwieback, and bread- 
crumbs in soup. 

Later: — 

Milk (raw) 8 ounces. 

Cream 1 / 2 ounce. 

Granulated sugar 1 teaspoonful. 

Warm in a saucepan and feed every four hours. 

Illustrative Case — Unsuccessful Laboratory Feeding. — N. K., a 
healthy female, was put, soon after birth, on modified milk. 

October 14th: Fat, 2.0; milk-sugar, 5.0; albuminoids, 0.75; 
lime-w T ater, Vie- Eight feedings; 2 ounces in each. 

October 17th: Constipation. Fat, 2.5; milk-sugar, 6.0; albu- 
min, 1.0; lime-water, 1 / 16 . Nine feedings; 2 1 / 2 ounces in each. 

October 27th: Fat, 3.0; milk-sugar, 6.0; albuminoids, 1.0; lime- 
water, V 16 ; barley-jelly, 1 / 1B . Ten feedings; 3 ounces in each. 

November 5th: Fat, 3.5; milk-sugar, 6.0; albuminoids, 1.0; 
lime-water, 1 / 16 ; barley-jelly, Vis- Ten feedings; 3 ounces in each. 

November 17th: Fat, 4.0; milk-sugar, 6.0; albuminoids, 1.5; 
lime-water, 1 / ao ; no barley. Ten feedings; 3 ounces in each. 

November 19th: Curded stools, dyspeptic diarrhoea. Fat, 4.0; 
milk-sugar, 6.5; albuminoids, 1.0; lime-water, 1 / 20 . Ten feedings; 
3 ounces in each. 

The child did not increase in weight, had a rectal temperature 
of 100°, slightly furred tongue, vomited curds, had greenish stools 
containing undigested particles of fat and true casein and large 
masses of mucus. The diagnosis of dyspepsia infantum was made; 
hand-feeding was stopped, the child's alimentary tract was cleaned 
by giving cascara sagrada, and a proper wet-nurse was secured. 
The infant at this time was about 6 weeks old. The child nursed 
very well, and after a few days the stools were normal, both in 



LABORATORY MILK. 243 

consistency and color. The infant gained steadily from 4 to 6 and 
sometimes 8 ounces per week, until she was 7 months old, when 
suddenly the weight remained stationary. The child was bright 
and cheerful, but I deemed it necessary to have the milk of the wet- 
nurse examined by a competent chemist; a specimen of the same 
was secured in the usual manner described by me in a previous sec- 
tion on "Specimen of Breast-milk for Chemical Examination." 
This specimen was examined for the author by John S. Adriance, 
the chemist of the Nursery and Child's Hospital, who reported the 
following: — 

Fat 2.000 per cent. 

Sugar 7.431 per cent. 

Proteids 0.882 per cent. 

Ash 0.162 per cent. 

Total solids 10.475 per cent. 

Water 89.525 per cent. 

Specific gravity at 70° F 1.0316 

Reaction alkaline. 

In the chemical result above given it is very evident that a 
deficiency in the proteids exists; hence it accounted, not only for 
the stationary weight, but for the late dentition. The child did 
not gain an ounce in one month. We discharged the wet-nurse. 
The following food was ordered: — 

Milk 3 ounces. 

Cream 2 teaspoonfuls. 

Oatmeal-jelly 3 ounces. 

Lime-water 1 drachm. 

Milk-sugar 1 teaspoonful. 

Salt 1 pinch. 

Sterilize the above and feed every three hours, the above quan- 
tity being for one feeding. 

After the infant had taken this food for 6 days it was cheer- 
ful, had had one and two yellow stools daily, and gained 6 ounces 
in 6 days. 

The above case will illustrate: — 

1. That the child was decidedly dyspeptic while taking its 
modified milk for about 6 weeks. 

2. That for about 6 months the infant thrived very well on 
the milk of a wet-nurse. 

3. That the stationary weight of the infant and the chemical 
examination of the milk of the wet-nurse showed deficient pro- 



244 INFANT-FEEDING. 

teids, which accounted for this non-increase in weight and the late- 
ness in dentition. 

4. That a proper milk-mixture, which agreed very well, suited 
the requirement of this infant, and emphasizes the fact that we 
must individualize in each and every case. 

According to Starr, the question naturally arises: 
"Why should a food capable of being prescribed to ap- 
proach so nearly breast-milk in chemical composition, so 
uniform in its make-up, so sterile, and so easily and ac- 
curately varied to meet digestive emergencies, fail when 
put to a clinical test?" 

The answer is that it is impossible to make an emul- 
sion like milk from its component parts by a synthetic 
process. Let it therefore be distinctly understood that, 
once a milk-emulsion is broken up, as is done in centri- 
fuging milk and removing the cream, mixing the whole 
will never restore the uniformity of the emulsion that 
existed prior to this division. 

Time and again have I examined a drop of milk under 
the microscope and found an unevenly-divided emulsion 
of modified milk, resembling colostrum-milk. The macro- 
scopical examination of modified milk will always show 
a large amount of butter-fat swimming on top of each 
bottle of milk when it is cool. If this fat is part of the 
formula prescribed, then the modified milk does not con- 
tain its original amount of fat, and much more must be 
prescribed, to allow for the separation of the same. Hence 
it would seem that the percentage portion of the food must 
necessarily be incorrect. 

Starr says, also, that "in its composition all the fat is 
removed by a separator, and the food as prepared for the 
infant is a recombination of this fat and an alkaline so- 
lution of the proteids and sugar. In a word, the natural 
emulsion is destroyed. This, I think, in some way lessens 
the digestibility of the proteids and leads to conditions 
either of malnutrition or to an irritative diarrhoea with 
the expulsion of the undigested proteids in the form of 



LABORATORY MILK. 245 

compact curds — and this, too, despite changes in the pro- 
portion of the proteids ; for the partially starved children 
are attacked with vomiting or diarrhoea with fever if 
the percentage of proteids be increased (say, to 2 per cent, 
at ten months), and those having irritative diarrhoea are 
not benefited until the percentage is cut down to a starva- 
tion-point (0.75 per cent, in a child of three months still 
showed numerous curds in the evacuations). What a con- 
trast to normal breast-milk, an emulsion having over 2 
per cent, of proteids (Leeds) ! 

"I have never seen an infant from two to ten months 
able to stand a laboratory-mixture of stronger proteid 
percentage than 1.50, and have often seen cases of two 
months and more unable to digest a percentage of 0.50." 

This last statement of Starr's I cannot indorse. Sev- 
eral children fed by me were able to digest 2 and 3 per 
cent, of proteids at 6 to 10 months of age. The case of 
successful modified-milk feeding here given illustrates 
how a child about 5 months old received and assimilated 
2 per cent, of proteids, and when less than 6 months old 
digested 2.50 per cent, of proteids. Thus it is apparent 
that weak, dyspeptic infants require individualization. 

In domestic modification, of course, the same care 
must be taken to secure clean, pure milk and cream from 
healthy, well-kept cows. This is quite possible now in 
]\ T ew York, and is becoming easier each year, as more 
attention is being given to infant-feeding and greater 
demand is being made for a pure milk-supply. Pasteur- 
ization is as readily done in the nursery as in the labora- 
tory. Accurate measurement of quantities and cleanliness 
of vessels and feeding-bottles is equally possible and, in 
my experience, quite as certain at home as in the shop. 

"The milk and cream from a dairy may vary slightly 
in chemical composition from day to day, but this varia- 
tion seems to me to be a minor detail, and of questionable 
importance when compared with the separator's destruc- 
tion of the physical properties of the basal milk. One 



246 INFANT-FEEDING. 

certainly would not sacrifice everything to chemical ac- 
curacy." 

Clinical experience has demonstrated the fact that 
some children will thrive on condensed milk in spite of 
faulty hygiene, while others will not thrive in the best 
environment with the best form of feeding; again, some 
children will thrive on modified milk, others will not. 
Some cases seen by the author suffered with intense con- 
stipation, having clay-colored stools. In one instance, in 
which two children in one family were constantly fed on 
modified milk of varying proportions, the formulae were 
changed at least a half-dozen times with the usual increase 
of fat and sugar and lowering of the proteids, and in spite 
of this fact, after repeated trials, and no benefit, this feed- 
ing-method was abandoned. A child recently seen by the 
author did not gain one ounce in four months. This was 
one of the reasons that prompted the family to change 
both the physician and the food. The child, about two 
years old, was very pale, restless at night, quite peevish 
during the day, and decidedly backward in development. 
It could neither speak nor walk, although the teeth were 
well developed. From the time the modified milk was 
discontinued, and a nitrogenous diet given, the infant im- 
proved, and from last reports is quite well developed. 

Do not let us blindfold ourselves with the belief that 
an infant is thriving unless our baby shows a regularity 
in the increase of weight, sleeps well at night, for at least 
from six to nine hours continuously, and, above all, as- 
similates its food, as evidenced by regular, unaided move- 
ments of the bowels; such movements should be once or 
twice in twenty-four hours, have a yellowish-white color, 
and a mustard-like consistency. If the stool is hard or 
lumpy or pasty, like putty, then it is certainly abnormal, 
and shows improper food. The same is also true if the 
stool contains white particles of cheesy curds, showing a 
casein indigestion. In one infant, which had taken modi- 
fied milk continuously for seven months, an obstinate con- 



LABORATORY MILK. 247 

stipation was only relieved after full doses of codliver-oil 
and extract of malt were given for several weeks — aided 
by massage, besides changing the diet. 

It is therefore very necessary continually to watch the 
baby, and when abnormal conditions — such as anaemia — 
prevail it is wise to give restoratives for a long period in 
addition to the food. Try to note if the food is deficient 
in its nutritive elements, and, if so, change the formula 
so as to adapt it to the baby. Do not give medicine when 
the quality or quantity of food is deficient. Remedy the 
food first; then, if not satisfied, give medication. 

PALLOR OF THE SKIN. 

An unusual pallor of the skin, and also of the con- 
junctival mucous membrane, has frequently been noticed 
in modified-milk babies. In one instance an extreme 
leucocytosis was noticed for the treatment of which iron 
was given. An examination of a drop of blood showed 
a diminution of the red blood-corpuscles and an excess of 
the white blood-corpuscles. A decided haemic murmur 
was noticeable in the vessels of the neck, in a child, two 
years old, which had been fed continually on modified 
milk. 

Craniotabes, softening of the cranial bones, as well 
as very late closing of the anterior fontanelle has also 
been observed in some children fed with this form of 
food. A boy, 4 years old, a typical Walker-Gordon baby, 
who was fed exclusively on modified milk, now shows 
typical knock-knees, besides having been under the treat- 
ment of his physician for a general furunculosis of the 
scalp. The furuncles were of such size that they required 
incision several times; others opened spontaneously. 

Thus, I fully agree with Louis Starr, of Philadelphia, 
who, in his paper, 69 says: "I must not be understood as 
condemning laboratory-milk absolutely ; if its introduction 
has done nothing else, it has greatly advanced substitute 

69 Archives of Pediatrics, page 7, January, 1900. 



248 Infant-feeding. 

infant-feeding, by fixing the attention of the profession 
upon the importance of cleanliness and accuracy in the 
quantity and chemical composition of cows' milk foods 
and by placing the whole question upon a higher scientific 
plane than it has ever reached before." 

Sometimes predigested food is ordered with the addi- 
tion of peptogenic powder, the predigestion to be done at 
the laboratory. A great many physicians who formerly 
condemned percentage feeding have become converted to 
this method. 

Constipation, which is frequently encountered, can be 
remedied if the chemical and clinical causes are consid- 
ered. Superheated milk is one of the main causes. In 
spite of the many failures reported by feeding sterilized 
milk, we see hundreds of babies brought up on this line 
of feeding. 

Chemical changes are produced by subjecting the milk 
to a temperature of 212° F. for thirty minutes and fre- 
quently forty-five minutes. These changes take place, in 
the most vital elements of milk, such as albuminate of 
iron, phosphorus, and possibly in the fluorin. These ele- 
ments are present in a vitalized form, as they are derived 
from tissues that contain them. When we consider that 
children require phosphatic and ferric proteids in a living 
form, then we cannot continue with boiled- or sterilized- 
milk feeding for a too prolonged period without causing 
structural weakness. 

There are times when raw milk will cause too fre- 
quent stools; then it may be advantageous to resort to 
pasteurization or to heating the milk to 167° F. for about 
twenty minutes. 

I am convinced that prolonged, sterilized-milk feeding 
will result in rickets. I have had many cases of weak 
spine and bony structure in which nothing but improper 
food could be regarded as the etiological factor. These 
children were among the well-to-do, among whom excel- 
lent hygiene and proper nursing habits were rigidly en- 



LABORATORY ALILK. 249 

forced. Improvement was noted when sterilized milk was 
abandoned and raw-milk food, in addition to raw muscle- 
juice, grape-juice, and orange-juice, was prescribed. 

A great many unsatisfactory reports are heard regard- 
ing laboratory feeding. Some condemn laboratory feed- 
ing because it is patented. Others condemn the method 
after noting poor results. The strongest opponents of this 
method are Jacobi, of New York, and Starr, of Philadel- 
phia. It may be safe to add that they may yet be con- 
vinced of the value of procuring sterile food handled by 
competent people whose scrupulously clean methods must 
appeal to even the most prejudiced. 

A child seen by me recently, in consultation with Dr. 
John Logan and Dr. Julius Martinson, of this city, may 
prove very interesting. The child was a bottle-fed infant 
— less than a year old — suffering with vomiting and diar- 
rhoea; the symptoms of cholera infantum were very pro- 
nounced. The diagnosis of acute milk poisoning was 
made, and concurred in by the attending physicians. The 
milk was procured from a small laboratory in our city. 
I have had good reason to complain of peculiar methods 
of handling milk. Sour milk has been sent to patients of 
mine by unscrupulous dairymen after they had secured 
evidences of my good-will. Surely the Walker-Gordon 
laboratory cannot be held responsible for the mistakes or 
carelessness in other dairies or creameries. 

More recently the author has tried raw milk and 
cream modified at the laboratory, and has noted a great 
difference in the assimilation of such modified milk. 
Thus, while some experience herein reported has been 
bad, it is possible that a good part of the fault is due to 
overheating the milk. Changing the character of the pro- 
teid and altering the chemical relationship of the various 
ingredients must change its assimil ability, and hence the 
author would urge those who use the laboratory to insist 
upon having formulae compounded by using raw milk 
and fresh cream. 



CHAPTER XXXV. 

Forced Feeding. 

This is commonly known as gavage. This consists in 
forcing a small feeding-tube, a Xo. 7 rubber catheter, 
through the mouth and pushing it forcibly toward the 
pharynx and directly into the stomach. This feeding- 
tube consists of a black hard-rubber or glass funnel to 
which is attached a piece of rubber tubing about ten 
inches long; then a small glass tube (a connecting tube) 
over which is drawn the rubber Xo. 7 catheter. In case 
of emergency, nothing is handier as a connector than 
the glass portion of the ordinary medicine-dropper, the 
smaller end will serve to connect with the rubber catheter 
mentioned above, and over the larger portion of the medi- 
cine-dropper we draw the rubber tubing connected with 
the funnel. This little apparatus has been very neatly 
combined for the author's use bv Messrs. George Tiemann 
& Co. (See Fig. 40.) 

Having pushed this small catheter into the stomach, 
we pour the food, usually several ounces of peptonized 
milk, or dextrinized barley and milk, or albumin-water, 
or the white of a raw egg mixed with half of a teacup of 
coffee and milk; or, if desired, a good concentrated soup, 
or bouillon, or broth, can be used. The same interval 
governing ordinary meals should be more strictly adhered 
to while this process of feeding is used. It is well under- 
stood that all instruments, utensils, and food must be 
strictly clean and sterile. 

Place the child flat on its back, and, first, pin either 

a heavy blanket or a stout sheet securely behind the body 

so that the hands are pinned down; have the assistant 

hold the child's elbows securely on each side; then force 

(250) 



FORCED FEEDING. 



251 



tlie mouth open and quickly pass the catheter, pour the 
food into the funnel, and when the funnel is empty with- 
draw the catheter as quickly as possible. If this forced 
feeding is done very slowly or clumsily, then nausea and 
sometimes vomiting will be produced thereby. Hence, 
the technique should be carried out as carefully as pos- 
sible. 




Fig. 40. — Author's Apparatus for Irrigating Rectum and well 
Adapted for Stomach-washing (Lavage) and also for 
Forced Feeding (So-Called Gavage). Also Useful in Nasal 
Feeding. 

Great care should be used in gavage. When children 
have teeth, the nurse must separate the jaws. For this 
purpose a piece of cork or a spoon covered with linen will 
answer as a mouth-gag. Accidents may happen if this 
precaution is not taken. The writer has seen several chil- 
dren who had bitten the catheters and swallowed them. 
In one of these cases the tube was easily dislodged by an 
emetic. Another required a gastrostomy. 



252 INFANT-FEEDING. 

NASAL FEEDING. 

Nasal feeding has long been in use where diseases of 
the mouth or spasm of the jaw or intubation in diphtheria 
rendered swallowing difficult. A thin rubber catheter 
is attached to a long rubber tube ending in a funnel; 
this is the same apparatus that has been described on page 
250. 

Modus Operandi. — Lay the child flat on its back and 
have a large sheet pinned over the body, so that the hands 
are firmly held; have the feeding-mixture all prepared, 
so that no time will be lost. A soft-rubber catheter, lubri- 
cated with vaselin or glycerin, is gently pushed into the 
nostril and glided through the pharynx into the oesopha- 
gus and stomach. When the tube is in the stomach, pour 
the required amount of food into the funnel so that it 
flows in the stomach. When the proper amount has been 
used, withdraw the catheter from the nose, and boil it in 
warm water to properly sterilize it for the next feeding. 

Quantity of Food. — The quantity of food used in 
nasal feeding should be somewhat less than is ordinarily 
used in health. It is understood that only liquid foods 
— like peptonized milk, sterilized milk, soups, and broths, 
or bouillon — can be used for feeding in this manner. A 
thin emulsion of egg can also be used. Owing to the fre- 
quency of both nausea and vomiting, which may be in- 
duced by irritation of the fauces, while the tube is gliding 
through the pharynx into the oesophagus, a much larger 
interval must be given between the feedings. It is de- 
sirable to introduce the tube rapidly and remove it rapidly 
if it is at all possible. Accidents will result in nasal 
feeding if a large quantity of liquid food is regurgitated 
through the oesophagus into the mouth and aspirated 
through the larynx into the trachea. 

In some instances it is easier to pass a soft, flexible 
catheter through the right or left nostril into the oesopha- 
gus, and forcibly push the same into the stomach. This 
is a very simple process, and I have never yet been able 



FORCED FEEDING. 253 

to pass the tube into the larynx while gliding it toward 
the oesophagus. All food should be given warm — prefer- 
ably between 98° and 100° F. Small quantities of milk, 
strained gruel, broth, or albumin-water will be far better 
digested than heavier food. In some instances, where 
milk is not well borne, the ordinary unsweetened cream, 
in the proportion of 1 teaspoonful of cream to 3 ounces 
of water, will serve quite well. In other cases I have 
used very successfully several teaspoonfuls of Mellin's 
food diluted with an ounce of raw milk, to which 1 
ounce of boiling water was added. This latter mixture 
is highly nutritious, and scalds the milk, and does not 
require either pasteurization or sterilization. Eskay's food 
has served me very well in one case of gavage. Meat-juice 
and expressed steak-juice or roast-beef juice should not 
be forgotten. 



CHAPTER XXXVI. 

Feeding in Diphtheria-Intubation Cases. 

When an infant has a foreign body — the intubation- 
tube — in its throat, swallowing is more difficult, because 
the epiglottis cannot close entirely. Frequently, while 
swallowing there is coughing, gagging, and regurgitation, 
caused by fluids (food) trickling into the trachea. In 
this manner, it is claimed, schluck-pneumonia has fre- 
quently been caused, though Northrop and many others 
deny the possibility of this condition. If the child's head 
is turned to one side — either side — and swallowing is pro- 
voked in this manner, we can sometimes avoid this trick- 
ling into the trachea. Another method is to lay the child 
flat on its back and allow the head to hang lower than its 
body, and to feed slowly with a spoon. This is known as 
the Casselberry method of diphtheria feeding. 

If this method is not satisfactory, and if we find that 
we cannot get enough food into our patient, then we can 
resort to rectal feeding. 

Clinical Illustration of Rectal Feeding in Diphtheria. — The fol- 
lowing clinical record will illustrate the manner employed in rectal 
feeding in private practice, with the aid of a competent trained 
nurse, in a case of severe laryngeal diphtheria which required in- 
tubation; child seen in consultation with Dr. H. Weinstein: — 

Feeding by mouth was discontinued while the child had a tube 
in its larynx: in all, a period of five days. 

The feeding was accomplished by first flushing the rectum 
and colon with a soap-suds enema to clean the bowel. After the 
bowel was emptied the peptonized food was introduced high into 
the colon. Food used: — 

Peptonized milk 1 ounce. 

Starch-water 1 ounce. 

To make starch-water take 1 teaspoonful of starch to 1 ounce 
of water. 

(254) 



9.00 


A.M. 


10.30 


« 


11.00 


n 


2.00 


P.M. 


3.00 


n 



FEEDING IN DIPHTHERIA-INTUBATION CASES. 255 

Alternate with: — 

Peptonized yolk of egg. 
Starch-water, 1 ounce. 

Feed per rectum every four hours. 

One day's record of case: — 

Intubated. 

Rectal irrigation (soap-suds). 
Nutritive enema (which was retained) : — 
Peptonized yolk of egg. 
Starch-water, 1 ounce. 
Bowel irrigated. 
Nutrient enema (which was retained) : — 

Peptonized milk 1 ounce. 

Starch-water 1 ounce. 

6.00 " Greenish stool with undigested milk-curds. 

Bowel irrigated. 
7.00 " Nutrient enema (which was not retained) : — 
Peptonized yolk of egg. 
Starch-water, 1 ounce. 
10.00 " Bowel irrigated. 
10.30 " Nutrient enema (which was retained) : — 

Peptonized milk 1 ounce. 

Starch-water 1 ounce. 

Bear in mind that the rectum absorbs, and does not 
digest. Hence, all food must be peptonized. The method 
is very simple. First: Always cleanse the rectum. This 
is done by washing the rectum with an enema of a pint 
of soap-water made by dissolving ordinary Castile soap 
or glycerin soap in warm water. The temperature of the 
soap-water should be 100° to 110° F. Quantity, from 
1 to 2 pints. After the rectum is cleaned, and the fsecal 
movements all passed, it is advisable to wait about five 
minutes to give the rectum a chance to rest. Then we 
proceed to inject the rectum with a suitable quantity of 
peptonized egg. Small quantities are better borne than 
large quantities ; hence, no more than 1 to 2 ounces should 
be thrown in at one time. 



256 INFANT-FEEDING. 

For rectal feeding the following are required: — 

1. Faircliild peptonizing tubes. 

2. Starch-water made by adding 1 teaspoonful of 
starch (raw) to 1 ounce of water (lukewarm). 

3. Fresh-laid eggs. 

4. Fresh raw milk. 

5. Rectal syringe or a fountain-syringe. 

6. Colon-tube for flushing the colon and rectum; the 
same tube can be used for injecting the peptonized food 
after the enema has acted. 

The following formula will give an idea of the way 
in which food is to be prepared for rectal injection: — 

Take 2 teaspoonfuls of ordinary starch and rub the 
same up with an ounce of lukewarm water.. This makes 
a very milky mixture. To this mixture we add the yolk 
of 1 egg, and one-half of an ordinary Fairchild pepto- 
nizing tube. This is to be slowly, but forcibly, injected 
into the rectum. Various methods of injecting can be 
used, the simplest being wuth the aid of a bulb rectal 
syringe, known as the infant's rectal syringe. (See Fig. 
42.) 

Another method consists in pouring this emulsion of 
starch-water and peptonized egg into a funnel ending in 
a rectal tube, a so-called rectal feeding-tube made by Tie- 
mann, of A T ew York City. (See Fig. 40.) 

The secret of success is undoubtedly the amount of 

t/ 

food brought into a child's body during its illness, and, 
the more food absorbed the greater resistance will the 
child have. It is advisable not to overtax the rectum; 
hence, my method of feeding is to use the peptonized 
yolk of egg with starch-water as mentioned above, and 
follow it — four hours later — by substituting an ounce of 
peptonized milk instead of the yolk of egg. 

With this ounce of milk an ounce of starch-water 
should be combined. If there is looseness of the bowels, 



FEEDING IX DIPHTHERIA-IXTUBATIOX CASES. 257 

and the food will not remain in the rectum, then 1 or 2 
drops of the ordinary tincture of opium added to each 
enema will soon quiet the irritation of the rectum, and 
thus aid in retaining the nutrient enema. 

At the Willard Parker Hospital feeding in diphtheria 
is chiefly done by gavage through the nose. The child 
is placed on its back and fed in the same manner as de- 
scribed by me under the heading "Mouth Gavage." While 
making rounds through the wards I have seen children 
gavaged through the nose, some lying on their backs 
and others while sitting erect. The only objection to this 
form of feeding is the possibility of pushing membrane 
downward through the nose or naso-pharynx. This might 
result in an infection of a healthy surface or in denuding 
membrane; epistaxis is likely to occur. 



17 



CHAPTER XXXVII. 

General Rules for Rectal Feeding. 

In another chapter entitled "Rectal Feeding in Diph- 
theria" attention has already been given to the method 




Fig. 41. — Author's Double-Current Rectal Tube for Flushing 
the Colon and Rectum and Used for Rectal Feeding. 




Fig. 42. — Rectal Syringe. 



of cleansing the rectum, and also to the injection of foods. 
The same rules are applicable when there is excessive 
(258) 



GENERAL RULES FOR RECTAL FEEDING. 



259 



irritability of the stomach, with constant vomiting and 
where it is desirable to give the stomach absolute rest. 




illilHili 

Fig. 43. — Rectal Syringe. 

Small quantities properly injected will be retained and 
absorbed much easier than large quantities of food, which 
will merely serve as irritants and be expelled. 



CHAPTEK XXXVIII. 

Feeding Children Afflicted with Cleft Palate. 

An infant born with cleft palate has a greater struggle 
for existence than a child born healthy, without this de- 
formity. It is advisable to give the best possible food, 
and, therefore, breast-milk only should be used. The milk 
should be drawn from a woman's breast as previously de- 
scribed in the section on "Specimen of Breast-milk for 
Chemical Examination." 

An artificial nipple should be attached to the feeding- 
bottle, and to the former should be attached a flap of 
India rubber so made that it fits the roof of the mouth. 
The pressure of the nipple against the piece of rubber, 
when in position, converts it into an artificial palate-piece, 
and prevents the escape of the milk into the nose during 
the effort of swallowing. This shield is chosen to avoid 
permitting curdled milk to pass into the recesses of the 
turbinated bones and to cause aphthous patches. 

It is advisable to operate on an infant for this de- 
formity between the third and sixth months of its life, 
if sufficient progress in its development will warrant it. 



(260) 



CHAPTEK XXXIX. 



Ikfaxt-stools. 



Stool of a Nursling. — The stool of a nursling or a 
baby on an exclusive milk diet should be yellowish in 
color, smeary or pasty-like in consistency, and have an 
acid reaction. The smell should be faintly acid, but not 
disagreeable. The color is due to bilirubin, and the reac- 
tion depends on the presence of lactic acid, the source 
of which is the milk-sugar. The only gases present are 
H and C0 2 . According to Escherich, H 2 S and CH 4 , to 
which the odor of adult stools is due, are not present. 
There are no peculiar albuminoids. Those existing in 
mothers' milk seem to be entirely absorbed. Peptone ex- 
ists in trifling amount. Sugar is not present. Pancreatic 
ferment is absent, and sometimes traces of pepsin have 
been found. Mucus is always present in considerable 
quantity; also columnar intestinal epithelium. 

In the stools of nurslings large quantities of lactate 
of lime can be found; so also we frequently find oxalate 
of lime, depending on the quantity of oxalate of lime in- 
gested. Urlelmann has noted the presence of bilirubin 
crystals in the stools of nurslings, in perfectly healthy 
children. 

Miller, who carefully studied the various micro- 
organisms in the mouth, found that most of them could 
again be found in the intestinal canal. He further found 
that certain germs possessed diastasic properties and were 
capable of producing lactic-acid fermentation. In the 
milk-faeces of nurslings Escherich found two germs; the 
one he called bacterium lactis aerogenes (or bacterium 
aceticum, Baginsky) and the other the bacterium coli 
commune. In the meconium he found proteus vulgaris, 

(261) 



262 INFANT-FEEDING. 

streptococcus coli gracilis, and bacillus subtilis. The 
number of stools during the first two weeks is from 3 to 
6 daily. After the first month the average is 2 stools 
daily; many infants have 1, others 3 stools daily. This 
latter is due largely to the excessive quantities of water 
given to infants. 

As soon as the exclusive milk diet is changed to the 
mixed diet we then lose the characteristic infantile stool, 
and it resembles more that of an adult, though remain- 
ing softer and thinner throughout infancy. The stools 
become darker in color, assume the adult odor, and have 




Fig. 44. — Schering's Formalin Disinfecting-lamp. Well Adapted 
as a Deodorizer in the Nursery. 

more varieties of bacteria than those previously mentioned 
as found in the stool of a milk diet. 

Reaction of Stools. — Reaction of stools in diarrhoeal 
disease and in health is chiefly acid or, next in frequency, 
neutral. Alkaline stools are rare. Green-grass stools, 
usually acid, are seen in the early stage of dyspeptic diar- 
rhoea, the color from a pale greenish yellow to grass-green, 
owing to improper food. 

Wegscheider has shown that the green color is the 
result of preformed biliverdin. The condition in the in- 
testine, upon which the transformation of bilirubin into 
biliverdin depends, has been generally regarded as one of 
acid fermentation. 



INFANT-STOOLS. 263 

Experiments. — Pfeiffer's experiments 70 show this for- 
mer opinion to be wrong. He found that none of the 
acids formed in such fermentation — lactic, acetic, butyric, 
propionic, etc. — added to yellow stools outside the body, 
turned them green, but that they made them deeper yel- 
low. But dilute alkaline solutions added to fresh yellow 
stools turned them green after an exposure of thirty to 
sixty minutes, and strong solutions turned them, first, 
brown; later, after exposure to air, intense green. 

Typical Green Stools. — Typical green stools can be 
produced by giving an infant 2 or 3 grains of bicarbonate 
of soda. This I have tried dozens of times: the soda must 
be given for a few days. This explains Pfeiffer's alkaline 
theory. Typical green stools can also be produced by 
giving small or even large doses of calomel. If, after 
having given bicarbonate of soda and produced green 
stools, we give diluted hydrochloric acid in 5- to 10- 
drop doses, the yellow color will reappear in a few days. 
Rhubarb will also produce a yellow stool. 

Stools. — Stools which are pale yellow when dis- 
charged, and which afterward become green, are often 
seen in disease. They may be themselves neutral or alka- 
line in reaction; this latter may, however, depend on the 
admixture of urine. An excess of bile may often cause 
very green stools. 

Brown Stools. — Brown stools may be due to changed 
biliary pigment and to drugs: e.g., bismuth causes the 
well-known dark stool. So also tannic acid and all iron 
salts give the dark stool, which varies from a deep brown 
to a black color. 

Blood in Stools. — Blood from the stomach or small 
intestine frequently gives the stool a black color resem- 
bling tar. Thus, a practical point in Boas's "Diagnostik 
der Magen- und Darmkrankheiten" is that, the brighter 



70 "Yerdauung im Sauglings-alter bei Krankhaften Zustanden," 
'Jalirbuch for Kinderlieilkunde," B. 28, page 164. 



2G4 INFANT-FEEDING. 

the color of the blood, the lower down near the rectum 
and anus must the pathological lesion be looked for; the 
darker the blood, the higher up must the cause be found: 
e.g. , the diseased conditions exist in the stomach, duode- 
num, jejunum, etc., if the stool contain black blood. 
If the corpuscular elements of the blood are wanting, 
then the presence of blood can only be positively diag- 
nosticated by either a microchemical examination or 
by means of the spectroscope. The presence of red blood- 
corpuscles must always be regarded as a pathological 
factor. 

Brown Stools; Muddy Stools. — A brown stool in an 
infant is frequently caused by a diet of animal food or by 
a diet principally of broth. These stools have no distinct 
consistency nor reaction. In dyspeptic diarrhoea or in 
some forms of enterocolitis we have very offensive stools, 
and they resemble muddy water; with the latter there is 
considerable flatus during each movement. 

White or Light-Gray Stools. — White or light-gray 
stools usually are of a putty-like consistency, sometimes 
like dry balls on a diaper; sometimes they appear like 
ashes. Usually they are very offensive, consisting prin- 
cipally of fat. There is scarcely a trace of bile, or the 
latter may be absent altogether. 

Mucus. — Mucus is always present in all healthy stools, 
and is so well mixed with the stool that it does not appear 
as mucus to the naked eye. Any appearance, therefore, 
of mucus easily visible should be regarded as abnormal. 
Mucus is present in every form of intestinal disease : very 
abundant in inflammatory conditions affecting the large 
intestine, more so than in those affections of the small 
intestine, and especially so in inflammatory conditions of 
the colon, both acute and chronic. 

Jelly-like Masses. — Jelly-like masses of shreds of 
mucus, and cases where the stool consists chiefly of mucus, 
show that the affection is confined to the lower portion of 
the colon or that it is located in the rectum. 



INFANT-STOOLS. 2G5 

Long Shreds of Mucus. — Long shreds of mucus, fre- 
quently resembling false membrane, are often found in 
catarrh of the large intestine. If the shreds of mucus 
are intimately mixed with the stool, then we must look 
for the lesion quite high up, and if it comes from the 
small intestine it is usually stained from bile. If the 
lesion is low down the mucus is not intimately mingled 
with the stool. 

Dyspeptic Stool. — The first change noticed in the 
dyspeptic stool is the increase of fat. Often the stool is 
quite green and contains small pieces, of yellowish-white 
color, which vary in size from that of a pin-head to the 
size of an ordinary pea. Hitherto, from their color, they 
were supposed to be casein lumps. Wegscheider has 
taught us that they consist principally of fat. Baginsky 
has shown that large colonies of bacteria are contained 
in these lumps of fat. Frequently they are so numerous 
that it looks as though the stool were composed only of 
these cheesy lumps. They can be easily differentiated 
from real casein lumps by their solubility in alcohol and 
ether. 

Fat Diarrhoea. — Biedert and Demme have devoted 
considerable attention to this subject. 71 In some children 
the faeces showed 50 to 60 per cent, of fat, whereas the 
normal percentage in ordinary fasces varied from 13.9 per 
cent, (which is the normal quantity), according to UfTel- 
mann. 

Casein is not nearly as common an ingredient of 
faeces as is commonly supposed. Casein lumps can be 
seen in abundance in the course of a diarrhoea during an 
exclusive diet of milk. 

Quantity of Faeces. — The quantity of faeces varies, 
but it has been found that 100 grammes of milk-food will 
produce about 3 grammes of faeces, according to Baginsky. 



71 See Biedert: "Fett-Diarrhea/' in "Jahrbueh fur Kinderheil- 
kunde," 1878. 



2GG IXFANT-FEEDING. 

This is a vital point, but I have found it very difficult to 
determine, for in most cases the napkins of the infants 
are soiled with urine plus the faeces, thus adding to the 
gross weight. 

Proteids. — The proteids of milk are so thoroughly 
absorbed that only small traces of them can be found in 
the faeces, formal milk-faeces contain large quantities of 
bacteria, but chiefly two kinds, previously mentioned, viz. : 
bacterium lactis aerogenes (Escherich) and bacterium coli 
commune. Other germs, especially those of the proteo- 
lytic type (i.e., those that render gelatin fluid), are not 
found under normal conditions. 

Albuminous decomposition and its products — tyro- 
sin, indol, phenol, and skatol — are not found in milk-faeces. 
But lactic acid, acetic acid, formic acid, and other fatty 
acids are present, causing the acid reaction. 

Saccharin Ferment. — Yon Jaksch found a saccharin 
ferment in trie faeces of children. 

Peptonizing Ferment. — Baginsky found a peptonizing 
ferment also in infantile faeces. 

Escherich 72 says: "If albuminous decomposition with 
very foul offensive stools exists, these articles should be 
withheld from the diet and carbohydrates given, dextrin 
foods, sugars, and milk. If acid fermentation is present, 
with sour, but not offensive, stools, carbohydrates are to 
be withheld and albuminous foods given, such as animal 
broths, bouillon, peptones, etc. In the decomposition of 
milk, the sugar of milk, and not the casein, is usually 
broken up." 

Holt 73 says : "Regarding the exact indications accord- 
ing to which fat, sugar, and proteids of milk are to be 
varied, much remains to be learned." 



72 "Jahrbuch fur Kinderheilkunde," "Beitriige zur Antiseptichen 
Behandlungs-methode der Magen-Darnikrankheiten des Sauglings- 
alters." 

73 "Artificial Feeding," page 179. 



INFANT-STOOLS. 267 

Sugar is Too Low. — If the sugar is too low, the gain 
in weight is apt to be slower than when furnished in 
proper amount. 

Sugar in Excess. — Symptoms indicating an excess of 
sugar: Colic or thin, green, very acid stools, sometimes 
causing irritation of the buttocks; sometimes there is re- 
gurgitation of food and eructations of gas. 

Excess of Fat. — Excess of fat is indicated by the fre- 
quent regurgitation of food in small quantities, usually 
one or two hours after feeding. Sometimes an excess of 
fat causes very frequent passages very nearly normal in 
appearance. In some cases the stools contain small round 
lumps somewhat resembling casein, but really masses of 
fat. This has already been mentioned in speaking of the 
differentiation of true casein curds and small fat lumps 
by the solubility of the latter in alcohol or ether. 

Dry, Pasty Stools. — When too little fat is given, it is 
indicated by hard, dry, pasty stools, and usually constipa- 
tion. This can be easily remedied by the addition of 
cream three-fifths of which is fat. Holt speaks against 
increasing the fat above 4.5 per cent, in infants under six 
months old, and believes we should not go above 4 per 
cent. 



CHAPTER XL. 

Nathan Straus Milk-laboratories and Similar 

Charities. 

Since 1894, through the generosity of the Hon. 
Nathan Straus, pasteurized, modified, and natural milk 
has been supplied from laboratories and milk-depots scat- 
tered throughout New York City. Some of these are 
found in the different parks of the crowded portions of 
our city. Hundreds of thousands of bottles are dispensed 
annually in New York and in neighboring cities. Thus, 
in a report of the Board of Health of Brooklyn for the 
year 1895, we find that in Brooklyn 42,739 bottles were 
used. 

The infant-mortality has certainly been lessened dur- 
ing the last few years in these cities; a great deal of it is 
due to the education of the poorer classes living in tene- 
ment houses, by means of these laboratories, to the neces- 
sity of using boiled food, or call it sterilized milk, and 
boiled water. There are other factors which have less- 
ened the great infant-mortality in New York City. 

Let us not forget the difference in the cleanliness of 
the streets of this metropolis due to the energetic work 
of the late Colonel Waring. The weeding out of blocks 
of tenement-houses, and the substitution of small parks 
in the heart of the tenement-district must certainly be 
healthful. Whoever studies the development of rickets 
will find that it is not only the feeding, which is the 
prime factor, but it is the environment, the faulty dwell- 
ing, with its foul air and general unsanitary condition, 
that contribute to the poisoning of the air breathed by 
the infant; this poisoning is as distinct a toxcemic con- 
dition as it would be if a poison were injected directly 
(268) 



MILK LABORATORIES. 269 

into the body. Faulty food, be it breast-milk or cows' 
milk, is the prime factor. 

Having been on continuous duty in the children's 
service of one of the largest clinics in this city for over 
ten years, the author has noted many, many changes. In 
recent years the large number of excursions, notably the 
St. John's Guild, which gives an excursion every day 
during the hot summer months to the poor destitute 
children of our city, has certainly added to the health of 
many little ones. There are also numerous sectarian ex- 
cursions; so, for example, there is a Hebrew sanitarium 
giving excursions to Rockaway every day during the 
summer. Then there are numerous church excursions 
and charitable funds, notably the Xew York Herald Ice 
Fund, all of which have a tendency to invigorate the 
lives of these poor infants, and in this manner they can 
withstand the terrible heat of the summer months, and 
survive it. The sanitarv vigilance of the Board of Health 
of ISTew York City has certainly improved the sewage 
and drainage, looked after the water-supply, and certainly 
benefited the city. These factors must be taken into 
account in studying the mortality and the population. 
The blessing for NeAV York City will consist in giving 
it a pure, clean, and rich milk in which the stable, and 
cow, and milker's hands and all utensils are absolutely 
sterile. I cannot emphasize too strongly that the ideal 
milk of the future will not be sterilized milk, not pasteur- 
ized milk, but will be pure, raw milk, xsature, in the 
human breast, supplies her infants with raw milk at body- 
temperature; why must we feed our infants with boiled 
or steamed milk, especially so, when chemists have taught 
us that chemical changes take place in boiled as well as 
in sterilized milk, rendering the milk more indigestible 
than it was in its raw state? 

A vital point to remember is that the milk, when 
drawn from the cow, must be quickly cooled and must not 
be allowed to reach a temperature above 50° F. until used. 



270 INFANT-FEEDING. 

Such milk will not permit the development of bac- 
teria dangerous to health. 

Rapid cooling, then, — to repeat again, — is as impor- 
tant as the most absolute assurance of cleanliness and ster- 
ility of every utensil brought in contact with milking — so 
necessary to avoid introduction of filth or bacteria. 



CHAPTER XLI. 



Colic. 



Colic is one of the most frequent causes of crying in 
children. They not only cry loudly, but will suddenly 
shriek, and when put to sleep will awaken with a sudden 
start, and cry loudly. The legs are usually flexed or they 
will move their legs back and forth, or up and down. 
They will seem to bend the body on itself. These attacks 
are usually associated with constipation; hence, it is a 
good plan, when the child is restless and utters a painful 
cry, to see if the bowels have moved. It is well known 
that this colic may be as well associated with diarrhoea. 
The origin of all colic is certainly the stomach. When 
dyspeptic conditions, arising from undigested particles of 
food in the stomach, exist, then fermentation, resulting 
in gas-formation, is the result. Colic is frequently known 
by the terms of "meteorismus or tympanites," but in the 
latter conditions the abdomen is greatly distended, and 
there is a permanent enlargement of it. Borborygmus can 
usually be made out, if the ear is applied to the abdomen. 
The vast majority of cases of colic have their seat in the 
intestine, and can be relieved very quickly. 

Worms (ascarides) have been known to cause colic. 
Besides, when there is a general loss of tone on the part 
of the muscular layers in the walls of the intestine, colic 
will frequently result. Jacobi believes that colic can be 
caused by chronic peritonitis resulting in adhesions or 
local changes in the walls of the intestine that will pro- 
duce local contractions or dilatations. 

An excellent preparation to relieve colic is calcined 
magnesia, or milk of magnesia, made by Phillips. Hare's 
"System of Medicine" contains an article by Stewart ad- 

(271) 



272 INFANT-FEEDING. 

vocating its use. It has served the writer very well espe- 
cially in young infants, where acidity was prevalent. A 
half-teaspoonful several times a day was enough in some 
cases, while others required several teaspoonfuls during 
the day. It is valuable where constipation exists, and can 
be added to the bottle of food. 

The treatment of colic is simple when the cause is 
known. The quickest method of relieving colic is to 
give an enema of soap and water or of warm chamomile- 
tea. I usually take an ounce of German chamomile- 
flowers and steep them in a quart of boiling water for 
from ten to fifteen minutes, then strain. The injection is 
to be given in the same manner as will be described in 
detail in the chapter on constipation. My method is to 
allow 1 or 2 pints of chamomile-tea at a temperature of 
100° to 110° F. (no hotter) to flow slowly into the rectum, 
and by all means the colon. AVhen the colon is thor- 
oughly flushed with this warm tea, and emptied of its 
faeces, it is usual for the attack of colic to cease. In addi- 
tion to washing the colon, it is a good plan to apply a 
small bag of either chamomile-flowers or slippery-elm 
bark, or ground flaxseed meal. To do this, I make a bag 
of cheese-cloth, capable of holding from 1 to 2 ounces, 
and then fill it with one of the above-mentioned ingre- 
dients; sew the bag shut when filled, and heat it before 
applying to the abdomen. Several of these bags can be 
made and kept in readiness, so that they can be applied 
quickly. It is a good plan to have one heating on the 
stove, while another is on the abdomen. These little bags 
are very grateful, and we are frequently rewarded by 
having the infant not only expel wind shortly after they 
are applied, but also frequently fall asleep. 

MASSAGE. 

During an attack of colic gentle massage with warm 
sweet oil or melted vaselin or lard will certainly be very 
comforting to the child. My plan is to take a bottle of 



colic. 273 

oil, warm it by placing it in a kettle of warm water, and 
then to pour it on the abdomen. The distended abdomen 
should then be thoroughly kneaded, and the gas expelled. 
Then the warm applications mentioned above can be ap- 
plied. 

DRUG TREATMENT. 

If the colic originated from a fermentative dyspep- 
sia, then treatment must be directed to the stomach. For 
this purpose antifermentatives, like the mistura rhei et 
sodas, should be given in doses of 1 / 2 to 1 teaspoonful, 
diluted with water, every two or three hours until there 
is a thorough evacuation. Very good results will be 
found, after the bowel has been cleaned with the quart 
of chamomile-tea previously mentioned, by administering 
from 5 to 10 grains of bismuth; I prefer to use beta- 
naphtol or the subnitrate; 1 / 2 -grain doses of resorcin will 
also be found useful. Paregoric in doses of 15 drops to 
1 / 2 teaspoonful should be administered with great cau- 
tion to children of six months or older. It is understood 
that no physician will forget the danger of giving re- 
peated doses of paregoric or permitting the same to be 
administered by incompetent people not aware of the 
dangers of the drug habit. The author has not only seen 
distinct opium poisoning follow the use of paregoric, but 
has also had occasion to see the distinct opium habit in 
very young children. This was reported by the author 
in a paper read before the New York County Medical 
Society, January 22, 1894, which was published in ex- 
tenso in the Medical Record of February 17, 1894. For 
an infant during the first few months, it is hardly safe 
to give more than 5 drops of paregoric, repeated in an 
hour if there is no relief. Another drug that has served 
the author very well is Hoffmann's anodyne in doses of 
from 1 to 5 drops, repeated in an hour if necessary. For 
an infant up to two months 1 drop per dose; from two 
to four months, 2 drops per dose; four to six months, 3 

18 



274 INFANT-FEEDING. 

drops; six to nine months and until one year of age, 4 
drops; children from one to two years, 5 drops. This is 
to be given in a teaspoonful of sterilized water. Another 
valuable drug, and one that is to be given cautiously, and 
in the same doses as Hoffmann's anodyne, is spirit of 
chloroform; never should more than from 1 to 4 drops 
be given to a child up to one year of age, and younger 
children less in proportion. I cannot favor the admin- 
istration of nauseating or foul-smelling drugs, such as 
asafoetida. We must try to cater to an infant's taste, 
especially so when in pain. 

THE USE OF SUGAR. 

When colic is caused by an excess of sugar, there will 
be considerable eructations of gas, and, frequently, small 
quantities of food will be regurgitated. 

The stools, when an excess of sugar is given, are thin 
and greenish, smell very acid, and usually produce a red- 
dened excoriation of the buttocks around the anus. 

When children show a tendency to the development 
of gas and have constant recurring colic, my plan is to 
discontinue the use of sugar until such time as this 
fermentation is absent. To sweeten the food I use small, 
saccharin tablets, 1 grain being ample to sweeten 1 pint 
of food. When there is a tendency to constipation, it is 
possible not only to sweeten the food, but also to modify 
this constipation by adding 1 teaspoonful of pure glycerin 
to each bottle of food prepared. A teaspoonful of malt- 
extract will also relieve constipation. 

EXCESS OF PEOTEIDS. 

A careful observation of the stools would easily show 
whether the albuminoids are in excess, for they are usually 
present in the form of curds. This condition is usually 
associated with constipation, and the indication would be 
to cut down the quantity of curd administered. 



CHAPTEK XLII. 

Constipation. 

To consider the cause of constipation during the 
nursing period let us first look into the mechanical cause. 
Concetti, 74 in a very elaborate article, gives the various 
anatomical reasons for constipation. He states that 
Huguier, in the Bulletin cle V Academie cle Medecine, had 
reported this same pathological condition several years 
prior to Jacobi, of Xew York. Thus, Huguier advises, 
as a practical point, that when a colotomy was to be per- 
formed in an infant it would be wiser to perforin the 
same on the right side rather than on the left. He stated 
that it was much easier, owing to the greater number of 
flexures, to reach the same by operating on the right side 
in cases of atresia of the anus. Concetti further states 
that Jacobi, in 1868, reported in the American Journal 
of Obstetrics an elaborate article, which has since appeared 
in the "Therapeutics of Infancy and Childhood" (A. 
Jacobi, 1887), giving the anatomical reasons in detail. 
They are well worth noting: — 

The embryonic intestine is formed in separate di- 
visions. There is no ascending colon up to the fourth or 
fifth month of foetal life. It is very short in the mature 
newborn. Despite this, the large intestine of the mature 
foetus is longer in proportion than that of the adult. It 
is three times as long as the body of the foetus, while 
it is only twice as long in the adult. 

There is the same disproportion with regard to the 
length of the small intestine. The small intestine of the 
foetus in the ninth month is twelve times as long as its 

74 Archiv fur Kinderheilkunde, vol. xxvii, 1899. 

(275) 



276 INFANT-FEEDING. 

body. The small intestine of the adult is only eight times 
as long as the body. 

The colon ascendens being very short, the surplus of 
length, particularly as the transverse colon also is not 
long, belongs to the descending colon, and especially to 
the sigmoid flexure. Drandt found it between 8 and 24 
centimetres in length, averaging from 14 to 20. I have 
seen a case in which it was 30 centimetres long. 

As the pelvis is very narrow, the great length of the 
lower part of the large intestine is the cause of multiple 
flexures, instead of the single sigmoid flexure of the adult. 
Thus it is that, now and then, two or even three flexures 
are found, and to such an extent that one of them may 
be found to extend as far as the right side of the pelvis. 
Cruveilhier and Sappey speak of this position of the lower 
part of the intestine in the right side of the pelvis as 
an anomaly. Huguier finds it on the right side of the 
body in the majority of cases. Others only occasion- 
ally, although they admit the great length of the sig- 
moid flexure. In common with Huguier, who even 
proposes to operate for artificial anus in the right side, I 
have found one of the flexures on the right side many 
times. 

The great length of the large intestine and the multi- 
plicity of its flexures are of great functional importance. 
At all events, they retard the movement of the intestinal 
contents, facilitate the absorption of fluids, and thus the 
faeces are rendered solid. When this length is developed 
to an unusual extent, constipation is the natural result. 
In the American Journal of Obstetrics, August, 1869, I 
have described two cases in which the descending colon 
was so long that the diagnosis of imperforate rectum was 
made. In one of them the operation for artificial anus 
was performed. Such cases and such errors are certainly 
very rare ; still there are those in which normal anatomical 
conditions will lead to incidents of great pathological im- 
portance. 



CONSTIPATION. 277 

Other cases of constipation in the infant may be 
classed under four heads: — 

First. — The intestinal mucus is deficient or too vis- 
cid. Such is the case in febrile conditions, now and then 
in chronic intestinal catarrh, and also when there is too 
much perspiration and secretion of urine. 

Second. — Improper condition of food. A super- 
abundance of casein, particularly cows' casein; of starch; 
the absence of sugar, and the administration of astrin- 
gents and iron. 

Third. — Incomplete peristalsis, such as exists in the 
rachitic debility of the muscular layer, in the muscular 
debility dependent upon sedentary habits and peritonitis, 
intestinal atrophy, and hydrocephalus. 

Fourth. — Mechanical obstruction. Cystic tumors in 
the intestine. There is, further, intussusception and twist- 
ing of the intestine, incarcerated hernia, even umbilical 
hernia, hardened faeces, and imperforations. 

In all these cases the diagnosis should not be made 
without manual examination. In most of the cases the 
abdomen is inflated, though it be painless. The faeces 
come away in small, hard lumps or in large masses. The 
liver and spleen are displaced. The liver may be so 
turned that a part of its posterior surface comes forward. 
The abdominal veins are enlarged to such an extent that 
they form circles around the umbilicus, similar to what 
is seen in hepatic cirrhosis. These children lose their 
appetite, sometimes vomit, and the irritation produced by 
the hardened masses in the intestinal canal may be such 
as to finally result in diarrhoea, which, however, is not 
always sufficient to empty the tract. 

There is, besides, an apparent constipation, which 
should not be mistaken for any of the above varieties. 
^Now and then a child will appear to be constipated, have 
a movement every two or three days, and at the same 
time the amount of faeces discharged is very small. This 
apparent constipation is seen in very young infants rather 



278 INFANT-FEEDING. 

than in those of more advanced age. Such children are 
emaciated, sometimes atrophic. They appear to be con- 
stipated because of lack of food, and not infrequently 
this apparent constipation is soon relieved by a sufficient 
amount of nourishment. 

Constipation resulting from a superabundance of 
starch in the food is easily cured by the withdrawal of 
the latter. 

Constipation produced by too much casein in the food 
will be relieved by diminishing its quantity. The propor- 
tion of casein in the food of infants should never be more 
than 1 per cent. Besides, this amount of casein ought 
to be copiously mixed with a glutinous decoction. 

Infants that have been fed on starchy food or even 
such cereals as barley, should have oatmeal substituted 
for the barley. 

Constipation depending on lack of sugar is very often 
speedily relieved by increasing the quantity of sugar in 
the food. This is the case, not only in artificial feeding, 
but also when the children are fed normally on breast- 
milk. Such mothers' milk as is white and dense, and 
contains a large amount of casein, is made more digestible, 
and will produce better evacuations, when a piece of loaf- 
sugar dissolved in tepid water is given immediately before 
nursing. 

As there is frequently a large excess of acid in the 
intestine, magnesia with or without rhubarb, will fre- 
quently relieve the acidity and cause a movement of the 
bowels. 

In a previous section on "Cream" I have already 
spoken of the deficiency of fat, which is one of the most 
frequent causes of constipation. Hence, in an infant 
nursing at the breast it is wise to give the child a tea- 
spoonful of raw cream immediately before taking the 
breast to correct the constipation. Cream consists of so 
much fat that in this manner we add fat directly to our 
food. This is the secret of success attained by some 



CONSTIPATION. 279 

authors when they advise giving codliver-oil, butter, 
olive-oil, or fried bacon to very young children. Each 
one desires to remedy the deficiency of fat in his own 
particular manner. 

A DRINK OF WATER. 

From infancy, when the child is but a few days old, 
we should make it a rule to give it a drink of water; thus 
a very small infant during its first week can be given two 
to three teaspoonfuls of boiled water during the day. A 
safe plan is to give this drink of water when it is not 
time for feeding, and if the child appears restless. It is 
understood that we must first satisfy ourselves that the 
child has not had a stool, is not lying in a soiled napkin, 
and that other conditions — such as colic — do not cause 
uneasiness in the baby. When a child is several months 
old, the quantity of water can be increased from teaspoon- 
fuls to as many winegiassfuls. Frequently have I noted 
the disappearance of a continued constipation after giving 
an infant its "drink of water" regularly. 

IMMEDIATE RELIEF OF CONSTIPATION. 

A rule that I have always followed, and one that I 
lay stress upon, is never to allow a child to retire at night 
without having had a movement of the bowels during the 
day. The reason for this is plain; not only will the 
accumulated faeces and gas cause flatulence, colic, and 
uneasiness, but this constant distension of the bowels will 
dilate the intestines to such a degree that frequently a 
permanent pendulous belly remains. 

My plan is to order an injection of a half -tumbler 
of ordinary glycerin mixed with a pint of warm water, — 
temperature, 100° F., — and to allow this quantity to flow 
into the rectum by using a fountain-syringe, the end of 
which has the smallest infants' rectal nozzle. In this 
manner we have a rapid emptying of the rectum and 



280 INFANT-FEEDING. 

colon, and can be assured of temporary and possibly per- 
manent relief. It is not absolutely vital to use glycerin 
and water, for a similar result can be obtained if we make 
soap-water by rubbing up a piece of Castile soap with 
a pint of warm water; or using glycerin soap with the 
equal quantity of water, if the latter soap can be pro- 
cured. 

Continued Use of Enema. — In obstinate cases it is 
well to slip a soft-rubber rectal tube over the nozzle, and, 
having anointed the rubber tube with vaselin or glycerin, 
the same can be pushed slowly into the rectum, then allow 
about half a pint of water to now into the rectum, which 
will distend it gradually, and, by simply pushing the tube 
farther into the colon, we can allow the balance of 1 pint 
or more to flow directly into the colon. The continued 
use (daily) of these enemas is not fraught with danger; 
on the contrary, these rectal injections can be used for 
months. In safe hands, if the mother or nurse is intel- 
ligent, there should be not only no injury, but positive 
good, from its continued use. 

REMOVAL OF SCYBALA. 

Hardened round balls or fragments of fseces will fre- 
quently be caused when the stool remains very long in 
the colon, or when the sigmoid flexure has an unusual 
length; in such instances the injection of either 1 / 2 pint 
of lukewarm sweet oil or glycerin will soften these scybala 
and aid in their expulsion. At times these balls will be as 
hard as marbles, and may require the aid of a small scoop 
(a very small teaspoon will do) to aid in their removal. 

DREG TREATMENT. 

A great many drugs are indicated and contra-indi- 
cated in the treatment of constipation. The intelligent 
practitioner does not desire merely one movement of the 
bowels, brought about by drugs, but seeks rather to use 




Fig. 45. — Funnel-shaped Depression of Sternum. Rachitic Ky- 
phosis. Deformity of Spine. Picture also Illustrates Ra- 
chitic Square Head. (From Author's Service in Children's 
Department of German Poliklinik.) 



CONSTIPATION". 281 

such therapeutic measures as will give a permanent cure. 
My choice of drugs is the following: — 

I£ Ext. cascara sagrada fl., §j. 
Glycerin, §j. 

Mix. Twenty drops of the above mixture in a teaspoonful of 
water three times a day, for children about three months old. At 
the age of six months, double the dose, or 20 drops three times a 
day. At the age of one year a teaspoonful three times a day. 

Another valuable preparation is malt-extract with cas- 
cara, in teaspoonful doses, once or twice a day. 

My plan is to give the first dose in the morning be- 
fore the feeding, and note the result. If the bowels move 
by noon-time then I discontinue the dose at noon, and 
give a second dose in the evening. If, however, there is 
no effect by noon-time, then I continue my second dose, 
and follow with my third dose in the evening. Thus, it 
will be apparent that, if one dose answers for the day, 
then we should discontinue the medicine for that day, 
but commence again on the following day, and keep up 
this form of drug treatment until it is apparent that the 
bowels are not as sluggish in their action as before. An- 
other drug which has been one of my stand-bys for many 
years is mix vomica. I give 1 drop of the tincture 
of mix vomica in a teaspoonful of sterile water three 
times a day, for an infant up to one year of age. Chil- 
dren of two years I give 2 drops three times a day. From 
three to six years, 3 drops three times a clay. Six to ten 
years, 4 drops three times a day. Ten to fifteen years of 
age, 5 drops three times a day. ISTux vomica is always 
to be administered on an empty stomach"; in other words, 
before feeding. Another valuable drug is rhubarb in the 
form of the aromatic syrup of rhubarb. From 1 / 2 to 1 
teaspoonful once or twice a day, repeated every two days, 
will frequently afford relief. 

Powdered rhubarb and magnesia, given in teaspoon- 
ful doses to very young children, is one of the best laxa- 



282 INFANT-FEEDING. 

tives and antifermentatives that we possess. It is espe- 
cially indicated for the relief of colic. 

Citrate of magnesia, given in wineglassful doses to 
children over one year of age once or twice a day, can 
also he recommended. 

In atonic conditions of the bowels depending on gen- 
eral weakness, strychnine, given in 1 / 200 grain doses twice 
a day, will be found useful. This may or may not be com- 
bined with iron. 

The infusion of senna-leaves is made by boiling a 
heaping teaspoonful of ordinary senna in a teacupful of 
boiling water for fifteen minutes, straining, and when 
cool adding 1 tablespoon of glycerin to 5 tablespoons of 
this infusion of senna. This quantity to be adminis- 
tered in three doses at intervals of four or five hours. 
In some instances the addition of syrup of manna will 
be found advantageous in sweetening the infusion of 
senna. 

Certain drugs should not be given. Of these castor- 
oil may serve as a type. The constipating effect following 
the use of castor-oil is so well known that this drug is 
indicated when we wish to cleanse the stomach and bowels 
and remove stagnant food, as, for example: in fermenta- 
tive dyspepsia accompanied by diarrhoea. Thus, we not 
only have an effective movement, but a constipating effect 
following the same. The use of drastic cathartics — such 
as scammony, elaterin, or podophyllin — should not be 
thought of in the treatment of infants and children. 
Very rarely do I use aloes, owing to its offensive taste. 
It is understood that calomel is only to be given when 
we wish to cleanse and produce an antiseptic effect in 
the intestine; for the treatment of constipation per se, 
calomel is entirely out of place. 

Suppositories. — Among those most commonly used 
are suppositories of the glycerin and gluten type. Gluten 
suppositories are made by the Health Food Company, of 
New York City. Most suppositories in the market are 




Fig. 46. — Rickets, showing Beaded Ribs. Breast-Fed Infant 
with Poor Hygienic Conditions and Delicate Mother. 
(From Children's Service of German Poliklinik.) 



CONSTIPATION. 283 

entirely too large, and frequently must be cut into halves 
and quarters. The suppository made by Parke, Davis & 
Co. has served the author very well. It should be dis- 
tinctly understood that a suppository is to be used in the 
evening for the same relief as we desire from the injection 
or enema previously mentioned. Xeither the suppository 
nor the injection should be used with the idea of curing 
a constipation. 

MASSAGE. 

Continued kneading of the abdomen with the aid of 
vaselin or oil will be found serviceable, and, if properly 
done, will provoke an action of the bowel. Thus it is 
that rubbing the abdomen with castor-oil has frequently 
been recommended in the treatment of constipation; the 
effect supposed to be due to the castor-oil is, in reality, 
due to the massage, and to nothing else. "When massage 
is used, it should be continued from five to ten minutes 
every day for one month, morning and evening. This will 
certainly aid and stimulate peristalsis, and ultimately tone 
the muscles and cure the constipation. 

ELECTRICITY. 

This is very valuable to stimulate peristalsis. The 
faradic, galvanic, or static current can be used. For the 
general practitioner the use of the galvanic current, five 
to ten cells, is sufficient. The negative pole (cathode) 
should be applied in the rectum, and the positive pole, 
which produces peristaltic waves, should be applied over 
the ascending, descending, and transverse colon. Local 
contractions result from the negative pole. A gentle 
faradic current applied over the spine and the abdomen 
will answer if used for several minutes in the absence 
of the galvanic current. Galvanic electricity should be 
used every day; frequently months are required to insure 
a cure, in conjunction with the medicinal and dietetic 
treatment. 



284 INFANT-FEEDING. 

DIETETIC TREATMENT. 

We have previously mentioned the value of cream, 
and the addition of water for the treatment of consti- 
pation. In bottle babies it is well to remember that oat- 
meal-water and sago-water should be used when constipa- 
tion exists. Under no condition should barley or rice be 
given, as the latter will simply increase the constipation. 
Older children should be given fruit, baked apples, 
peaches, prunes, grapes, and oranges, and avoid pears. 
Buttermilk will be found serviceable, as well as koumiss, 
for the relief of constipation. Sugar (cane-sugar) will 
be found quite serviceable, when added to water, for 
the relief of constipation in nursing or bottle-fed babies. 
Thus, a good plan, according to Jacobi, is to give a small 
piece of loaf-sugar dissolved in water immediately before 
nursing, and to substitute and use cane-sugar instead of 
milk-sugar for bottle-fed babies. 

Having regulated the diet and excluded fresh bread, 
cakes, pies, pastries, macaroni, and other floury foods, we 
should insist, in children over two years of age, on eating 
all green vegetables with the exception of cabbage, beans, 
turnips, potatoes, and corn. Thus, celery, spinach, green 
peas, asparagus, and cauliflower are recommended. 

EXEECISE. 

What massage is for a young infant exercise is for 
an older child. Thus, it is apparent that atonic condi- 
tions can best be relieved by combining the dietetic and 
medicinal treatment with out-of-door exercise. Children 
should be permitted to romp about and walk and play 
out of doors, but not to a point approaching fatigue. 
Older children will find bicycle exercise or horseback- 
riding decidedly beneficial. It is important, however, to 
regulate the amount of such exercise, and thus it is ap- 
parent that it is the physician's duty to tell the mother 
or nurse just how long a child should be permitted to 




Fig. 47. — Showing Rachitic Beaded Ribs on Left Side of Thorax. 



CONSTIPATION. 285 

exercise. It would seem that one-half hour twice a day 
is ample to arrive at beneficial results. Overindulgence 
in such sports will frequently result in rupture and pro- 
duce heart-strain. In cardiac lesions, in asthmatic con- 
ditions, if children suffer with whooping-cough, and in 
tuberculous conditions such exercises must not be allowed. 

HYGIENIC TREATMENT. 

We should insist on proper ventilation of a child's 
sleeping-room at night, and it is, therefore, advised that 
the window be left open a few inches. This is not fraught 
with danger; on the contrary, it is healthful and bene- 
ficial to allow children to play in the open air all day, 
and naturally to shut them up in poorly ventilated apart- 
ments at night is simply inviting both throat and lung 
trouble. In addition to proper ventilation, bathing in 
cool water or lukewarm water, followed by an abdominal 
spray or a douche directed against the stomach and bow- 
els, will be found advantageous in the correction of this 
ailment. Following the bath, friction with a good, coarse, 
Turkish towel will be found useful. My preference has 
always been for a lukewarm bath, followed by a cold 
douche for a few moments, every morning, and then to 
have the child properly rubbed until the skin is reddened 
with a Turkish towel, followed by massage with oil or 
vaselin. 



CIIAPTEK XLIII. 

Statistics. 

The recorded births of the three years 1890, 1891, 
and 1892, according to the New York Board of Health, 
were 135,602. 

It is estimated that this represents only five-sixths of 
the actual number born; so that 162,721 would really 
represent the actual number of births for this period. 
During the same time the number of deaths of children 
under five years of age were 52,213, representing over 
32 per cent, of the whole number of births. 

In July, 1893, the deaths of children under five years 
of age numbered 2796. During the same month of 1894, 
2562. In August, 1893, there were 1686. In August, 
1894, 1559. During eight months ending in August the 
deaths under five years of age were: 1895, 13,287; 1896, 
12,734; 1897, 10,962. During June, July, and August 
of 1896 there were 5671 deaths. During the same period 
of 1897, 5041. In 1897 and in 1902 we had a cool sum- 
mer. 

The following tables, compiled from the vital statis- 
tics of the Board of Health, show the relative death-rate 
and the infant-population in (old) New York City. 

Deaths and Death-rates of Children under Five Years 

of Age, for the Months of June, 

July, and August. 

Year. Population. Deaths. Death-rate. 

1891 188,703 5,945 126.0 

1892 194,214 6,612 136.1 

1893 199,886 5,892 117.9 

1894 205,723 5,788 112.5 

1895 212,983 6,183 116.1 

1896 216,728 5,671 104.7 

(286) 



STATISTICS. 287 

Year. Population. Deaths. Death-rate. 

1897 220,641 5,041 91.4 

1898 224,736 5,047 89.8 

1899 229,029 4,689 81.9 

1900 233,537 4,562 78.1 

1901 238,279 4,642 77.9 

1902 243,500 4,387 72.1 

Population, Deaths, and Death-bates of Children Under 
Five Years of Age from 1891 to 1902 
in (old) New York City. 

Tear. Population. Deaths. Death-rate. 

1891 188,703 18,224 96.6 

1892 194,214 18,684 96.2 

1893 199,886 17,865 89.4 

1894 205,723 17,558 85.3 

1895 212,983 18,221 85.6 

1896 216,728 16,807 77.5 

1897 220,641 15,395 69.8 

1898 224,736 15,591 69.3 

1899 229,029 14,391 62.8 

1900 233,537 15,648 67.0 

1901 238,279 14,809 62.1 

1902 243,500 15,019 61.7 

As the census authorities have not yet supplied the figures of 
the number of children living under five in our city, the above 
population represents an estimation based on the supposition that 
the same proportion of children under five to total population 
exists to-day as existed in the census of 1895 : 75 to wit, 11.37 per 
cent. 

The author desires to thankfully acknowledge the 
kindness of Dr. William H. Guilfov, of the New York 
Health Department, in furnishing the above statistics. 



According to the census of June 1, 1900, 11.46 per cent. 



CHAPTER XLIY. 

Rachitis (Rickets). 

Prof. Paul Zweifel, in his recent work (1900) on 
the above subject, says: "That the addition of water to 
raw milk aids in the digestion of the same, whereas the 
addition of an equal quantity of water to boiled milk 
produces just the opposite effect." Thus it would ap- 
pear, from the experiments of this author, that raw cows' 
milk diluted with an equal quantity or even more water 
will be much more easily assimilated than diluted boiled 
milk. 

Zweifel agrees with Schlesinger, of Breslau, "that 
the addition of water to milk does not render it more 
digestible." Clinical investigations by such authorities as 
Professor Baginsky, in Berlin, have proved conclusively 
that whole milk (undiluted) cannot be fed to infants with 
weak digestive powers or those suffering with dyspepsia 
without aggravating the dyspeptic conditions and threat- 
ening the very existence of the child. Time and time 
again has the author tried to increase the weight of chil- 
dren and to strengthen them by giving them more con- 
centrated food. These experiments would have proved 
disastrous in winter but for the rapid withdrawal and 
substitution of the requisite diluted milk solution neces- 
sary for the age of the infant. 

THE ADDITIOX OF TABLE-SALT. 

The addition of table-salt has given such satisfactory 
results when added to milk that Zweifel insists on its ad- 
vantage in preventing rickets. When a large-size thimble 
is filled with salt it will hold about 3 grammes. The 
smaller thimbles will hold about 2.5 grammes of salt. If 
(288) 



RACHITIS. 289 

this quantity (3 grammes) of table-salt is added to 1 pint 
of water (500 cubic centimetres), then we have a solu- 
tion approximating the decinormal salt solution commonly 
known as the physiological normal salt solution. Zweifel 
maintains that both sterilizing and boiling the milk, ac- 
cording to the Soxhlet method, does not render it more 
indigestible. On the other hand, he believes that the 
albuminoids of the milk are rendered more difficult to 
digest, and thus he believes that boiling might be a factor 
in producing rickets. 

Rickets is caused by the substitutes for milk rather 
than by milk itself. 

When children are improperly fed so that the body 
is underfed, muscle- and bone- formation will be slow. 
Thus it is that the eruption of the teeth will be delayed, 
and this is one of the most prominent symptoms of rick- 
ets. The bones show the most characteristic result of 
improper nutrition, for they are very soft and spongy. 
They will yield to the weight of the body if used in 
walking, and thus it is that bow-legs with extensive curva- 
tures form such a prominent feature in showing the result 
of using soft bones. The most typical symptoms can be 
studied on the head and spine. Thus, craniotabes can be 
explained by a deficient nutrition in which the cranial 
bones will be found so soft that they will yield to the 
pressure of the thumb. The cranial bones will frequently 
be found to be as soft and as thin as pasteboard. The 
spine is most frequently deformed, and will show a typical 
rachitic kyphosis. 

CAUSES. 

The majority of children suffering with rickets are 
or were bottle-fed children. Thus, it is apparent that no 
food can equal breast-feeding, be it mother or wet-nurse, 
in preventing rickets. There are a great many other 
causes, such, for example, as bad sanitary measures and 
faulty hygiene. Breast-fed children will sometimes show 



290 INFANT-FEEDING. 

rickets when they have been living in bad apartments, 
breathing foul air, and not being properly cared for. One 
of the most frequent causes of rickets is "prolonged" nurs- 
ing. In the section on "Breast-feeding" I have already 
pointed out the necessity for making a proper chemical 
examination of the breast-milk if the infant "shows no 
increase in weight." We know that, toward the end of 
lactation, not only do the proteicls diminish, but get to 
such a low percentage that, unless we combine hand- 
feeding by adding the raw white of egg, steak-juice, and 
other proteids, like the cereals, to the nursing, the child 
will be underfed. This underfeeding is certainly a con- 
tributing factor, both to the causation and leading to the 
development of rickets. 

Children that have suffered prolonged diarrhoeas or 
with severe diseases — like dysentery, typhoid, bronchitis, 
and pneumonias — are prone to the development of rickets. 
Children of syphilitic parents and whose parents are tu- 
berculous are more prone to the development of this 
disease. Yon Hitter, quoted by Professor Baginsky, says 
that, in twenty-seven cases out of seventy-one examined 
by him, rickets was not only found in the children, but 
as well in the mothers of these same cases. Thus it is 
that Kassowitz and Schwarz 76 have mentioned the exist- 
ence of congenital rickets. This same author found that 
80 per cent, of children born in the Vienna Lying-in 
Hospital were rachitic. This statement is not so easily 
accepted, however, for neither Professor Baginsky nor 
Virchow accept the same. Experimentally, it has been 
found as long ago as 1842 by Chossat that when lime 
is deducted from the nourishment of young animals 
not only soft bones result, but they finally die. Heitz- 
mann maintains that, if lactic acid is introduced into the 
food of young animals, the result will be, first, rickets, 
and, later on, osteomalacia will result therefrom. Clin- 



" Wiener medicinische Jahrbucher/' 1887, vol. viii. 



RACHITIS. 291 

ical investigations have shown that cases of rickets occur 
more often during the winter months; thus it is ap- 
parent that improper ventilation is one of the most ex- 
citing causes of this disease. 

The prognosis of infants suffering with rickets depends 
npon the amount of damage already done. If deformities 
of the spine, of the head, of the legs, and arms exist, 
careful orthopaedic treatment will certainly modify the 
condition. The backbone of the treatment will, how- 
ever, consist in studying "the dietetic requirements of 
the case." In this disease more than in any other will 
the advantages of a carefully regulated diet be apparent, 
if the hygienic factors and proper medicinal treatment 
are included. 

Rachitic children require milk, meat, and eggs; plenty 
of cereals, like wheat, barley, rice, farina, sago, oatmeal, 
hominy; they require butter, and, if they will not take 
butter, then codliver-oil or lipanin; iron will be found 
valuable, as well as Fellows's hypophosphites; malt-extract 
and ferrum lacticum are indicated. Great emphasis must 
be put on the value of fresh air and sunshine in the treat- 
ment of this disease. 

EXTERNAL TREATMENT. 

Bathing in sea-salt, taking 1 to 2 pounds of salt to a 
bath-tub of water, to which malt-extract, about 1 teacup- 
ful, is added; in the place of malt Baginsky advises 2 
ounces of calamus-root. I have seen very good results 
follow the continued use of bran and sea-salt, of which 
2 to 3 pounds of bran and a pound of sea-salt are placed 
in a bag made of cheese-cloth. This bag is put into the 
bath-tub one-half hour before putting the baby in it. 
Enough water is then added to bathe the child ; the tem- 
perature of the bath should be from 80° to 100° F., my 
preference being for a cool bath, really tepid, temperature 
of 90° F. ; duration of bath, from 5 to 10 minutes, fol- 
lowed by a good, brisk rub with a coarse Turkish towel. 



292 INFANT-FEEDING. 

Massage of the muscles aided by passive movements 
will be found very valuable in producing a better mus- 
cular development, aiding metabolism, and stimulating 
the circulation in general. The great susceptibility of 
rachitic children to colds and coughs, especially to croup, 
can certainly be modified if such children will be given 
cold baths, cold sponging, cold spray, or a cold douche. 
Such children should not be overbundled with clothing, 
and while I insist on protecting the lungs and the whole 
body from sudden changes in the weather, the use of too 
much clothing will certainly tend to increase the amount 
of perspiration, and thus add to, rather than mitigate, our 
trouble. 

INTERNAL TREATMENT. 

Kassowitz Formulae. — 

1. I£ Phosphori puri, 0.01. 

01. amygdal., 70.00. 
Sacch. alb., 30.00. 
iEther. fragar., gtt. xx. 

2. $ Pkosphori puri, 0.01. 

Solve in ol. amygdal. dulc, 10.00. 
Pulv. gummi arab., 5.00. 
Sirupi simpl., 5.00. 
Aq. dest., 80.00. 

3. IJ Phosphori puri, 0.01. 

Ol. amygdal., 30.00. 
Pulv. gummi arab., 15.00. 
Sacch. -alb., 15.00 
Aq. dest., 40.00. 

Of the above mixtures, 1 to 2 teaspoonfuls per day; 
so that children would receive 1 / 2 milligramme (0.0005) 
of phosphorus, and in prescribing 100 grammes of cod- 
liver-oil or in the emulsion containing the above-men- 
tioned dose of phosphorus the quantity would last twenty 
days. Formula Xo. 1, given by Professor Kassowitz, of 
Vienna, does not mix well; neither does Formula 3; so 
that Formula 2 is the only one available for practical 




Fig. 53. — - Athrepsia Infantum. 



RACHITIS. 293 

purposes, and may be used. A chemical test for the 
presence of phosphorus will always yield a positive result. 
Thus far the specific action of unoxidized pure phosphorus 
has not yet been proved. In fact, such keen observers 
as Baginsky and Henoch do not believe that phosphorus 
in its pure state is applicable. 

A very valuable drug in the treatment of rickets is 
the following: Glycerophosphate of lime, in doses of 1 
to 5 grains for an infant one year old, to be given im- 
mediately after feeding. For a child six months old one- 
half the dose. 

When this disease is associated with anaemia or very 
great weakness or where it is desirable to tone up the 
general system, then add to the glycerophosphate of lime 
an equal dose of the glycerophosphate of iron. This drug 
treatment should be continued for several months before 
expecting results. It is understood that the author insists 
on a radical change of diet, and also the strictest hygienic 
treatment, when possible. All factors will be more es- 
sential than merely giving an infant a few doses of drugs. 



CHAPTEK XLV. 

Scurvy (Scorbutus). 

This is a constitutional disease resulting from im- 
proper feeding. It usually occurs before the end of the 
second year, and rarely occurs before the first six months 
of a child's life. As in adults, scurvy is found when fresh 
food has been withdrawn from the dietary. It is natural, 
therefore, to look for scorbutic cases among children who 
are: — 

First. — Deprived of breast-milk. 

Second. — In those brought up exclusively on milk 
w T hich is devitalized by prolonged sterilization. 

Third. — It is found in children brought up on con- 
densed milks and proprietary foods to which fresh milk 
has not been added. There seems to be, therefore, a 
direct relationship between the absence of fresh milk, be 
it cows' milk or human milk, and the development of this 
disease. 

Profound anaemia and tendencies to haemorrhage usu- 
ally are the most prominent symptoms. The most im- 
portant symptoms are, according to Starr: First, immo- 
bility, progressing to pseudoparalysis; intense hyper- 
sesthesia and general swelling, situated most frequently 
in the legs, but not limited to these members; the in- 
vesting skin is shiny and tense, but there is neither 
oedema nor local heat; the subsidence of the general 
swelling reveals deep fusiform thickening about the shafts 
of the long bones, in the neighborhood of the joints. In 
extreme cases there is a tendency to fracture near the 
epiphysis. Second, the gums about the erupted teeth are 
swollen, and purple in color, and in marked cases become 
spongy and readily bleed. Third, the rapid disappearance 
(294) 




Fig. 54. — Athrepsia Infantum. 



scurvy. 295 

of all symptoms upon the institution of a proper anti- 
scorbutic diet. 

This disease is liable to occur in either sex; it is not 
influenced by climate or locality; it is found as well in 
the best as in the poorest hygienic surroundings. By far 
the greatest number of cases is found among the rich. It 
is evident that this disease is due to improper feeding 
more than to an improper hygiene. Some authors believe 
that this disease is caused by a specific micro-organism; 
this latter fact has not yet been definitely settled. 

It is interesting to note the various views expressed 
by competent observers upon this subject; thus, while a 
large majority of clinicians hold that sterilized milk per 
se does cause scurvy, Eotch states that it does not, in his 
own experience, seem to do so. Starr maintains just the 
reverse of Eotch, and believes that sterilized milk is a 
causative factor. From my own experience I quite agree 
that sterilized milk — especially the prolonged sterilization, 
by which the albumins are changed, and by which this 
prolonged heating causes devitalization, which is so inim- 
ical to successful feeding — is a causative factor in this 
disease. 

It is peculiar that scurvy will be cured by giving raw 
milk, fresh fruits, and acid fruits; yet still we find that 
a great many clinicians persist in prescribing sterilized 
milk until either rickets or scurvy is established. It was 
for this reason that at a discussion on infant-feeding at the 
Academy of Medicine, October 18, 1900, 1 was led to in- 
sist on the use of raw milk as the proper means of feeding 
children. 

Eaw milk possesses certain advantages over boiled 
milk; it is more readily assimilated and the proteids are 
not so difficult to digest. It is a well-known fact that 
boiled milk and sterilized milk have a tendency to produce 
constipation, whereas the opposite is true of raw milk. 

Improper infant-food has additional disadvantages 
when it is subjected to excessive heating. The large num- 



29G INFANT-FEEDING. 

ber of failures with milk modified at a laboratory are not 
so much due to the process involved in the modification 
as to the amount of heat that the food is subjected to 
prior to being imbibed. 

Where milk is modified for infant-feeding, using raw 
milk only, I have never seen constipation; the reverse, 
however, has always been true when milk was modified 
and then subjected to sterilization. The vital point has 
always impressed me as being, not so much to sterilize 
milk after it has been drawn from the cow, but to apply 
the principle of sterilization to the stable, the cow, the 
utensils, the milker's hands, and to everything coming in 
contact with the milk from the time it leaves the cow's 
udder until it is fed to the baby. 

When oatmeal-gruel or barley-gruel is given with an in- 
sufficient quantity of coivs' milk and then fed for a long time, 
we must not be surprised to find a case of scurvy. When 'pro- 
prietary foods are given without the addition of fresh milk, 
then scurvy will usually result. When cream-mixtures are 
given which are deficient in fat and proteids, then scurvy may 
result. Thus we find that the true, underlying cause of scurvy 
is starvation due to deficiency of one or more nutritive ele- 
ments in the food given. 

The following case of scurvy will illustrate the con- 
dition : — 

A child, 13 months old, was brought to me with a history of 
being very restless and having lost considerable weight. The child 
showed a shriveled appearance of the skin; its normal elasticity 
was gone; the skin was dry; the thorax was pigeon-breasted; the 
arms and legs were thin; both arms and legs showed marked ten- 
derness on the slightest motion; there was baldness at the occiput, 
and the anterior fontanelle was not closed; the child had eight teeth, 
all of which were slightly carious; the gums around the teeth were 
deeply congested and showed bluish ridges; the gums were spongy 
and bled very easily; there was an intense foetor to the breath; the 
child had been suffering from diarrhoea for the past two months, 
with occasional periods of constipation; there was no vomiting; 
the appetite had always been very poor. The previous history of 



scurvy. 297 

tlie child was that, when born, it weighed about 5 pounds; it was 
very small at birth. The mother of the child died during confine- 
ment, and hence the baby was given into the care of a nursery. 
The diet consisted of 1 teaspoonful of condensed milk with 12 
teaspoonfuls of water and a small pinch of. sugar. This was fed 
every two hours for a period of over two months; later the child 
was put on barley-water, to which some condensed milk was added. 
This was changed from time to time to a diet of oatmeal-water 
and condensed milk. 

The child had always been frail, and had had a cough and also 
had an attack of acute capillary bronchitis; during the summer 
the child had a severe attack of cholera infantum, and almost lost 
its life from vomiting and purging. For one month this child sub- 
sisted on a diet of oatmeal-water, rice-water, farina-water, and 
albumin-water, besides cold tea. Thus it is seen that the child re- 
ceived no milk for a period of over seven weeks. When the child 
was five months old it weighed 7 pounds, and at this time it hardly 
weighs 10 pounds. There is a marked rachitic kyphosis; the ribs 
are beaded; there is a pendulous belly; the child has an umbilical 
hernia; the temperature, taken in the rectum at 2 p.m. for a period 
of at least two weeks, was no higher than 100° to 101° F.j there is 
an intense thirst; the kidneys are very active; the urine has a 
very high color; no hematuria could be found. 

The diagnosis of infantile scurvy was made and the child was 
put on the following treatment: Orange-juice; lemonade; freshly- 
expressed steak- juice; raw milk, diluted with barley-water or rice- 
water, equal parts (4 ounces of milk, 4 ounces of barley-water), 
repeated every three or four hours, depending upon the appetite. 
Massage of the body was very gently performed with codliver-oil 
or vaselin, to lubricate and to nourish. A 1-drop dose of nux 
vomica was ordered before each feeding. This treatment was given 
continually for three or four weeks. Every fourth or fifth day a 
half- ounce of barley-water or rice-water was withdrawn, and instead 
an equal quantity of fresh milk was added; hence, after four 
weeks of treatment this child received 6 ounces of milk with 2 
ounces of barley-water or rice-water every four hours. 

The child was sent to the seashore, and after this treatment 
was continued for seven months all symptoms of scurvy had dis- 
appeared, though the symptoms of rickets were still very promi- 
nent. The prognosis now is very good, and the child will un- 
doubtedly recover. 

When children have walked, and suddenly stop walk- 
ing and will not creep, then attention should be directed 



298 INFANT-FEEDING. 

to the state of the gums and to the general physical con- 
dition. Such cases are usually suspicious, and show the 
beginning of the development of scurvy. Indeed, such 
symptoms will develop long before there is a general 
breaking-down. Emaciation and anorexia follow, which 
are associated in this condition. 



CHAPTER XLYI. 

Dentition (Teething). 

The teeth usually appear, according to Professor 
Baginsky, between the third and tenth months, though, 
as a rule, between the ninth and tenth months. The 
usual rule is for normal dentition to begin about the sev- 
enth or the eighth month. 

In a great variety of children premature teething is 
recorded; I have seen a great many children born with 
two and more teeth. 

Rachitic children, as a rule, teeth very early or very 
late. In the large children's service with which I have 
been connected I have observed the eruption of teeth 
many times as early as two or three months in very 
rickety, bottle-fed children. These teeth soon decay, and 
are then known as carious teeth. 

In syphilitic (congenital) children premature denti- 
tion is frequently seen. 

The first teeth are known as milk-teeth. 

The following table will show the usual rule followed 
by normal dentition in the average child: — 

19 | 11 | 13 | 5 | 3 | 4 | 6 | 14 | 9 j 17 
20~pL2~pL5 | 7 | f| 2 | 8 | 16 | 10 |~T8 

The milk-teeth are twenty in number; thus, 1 and 2 
are the lower incisors, usually first teeth; then follow 3 
and 4, upper incisors. 

Normal children usually teeth in pairs, and not singly, 
whereas rachitic children usually have an eruption of 

(299) 



300 



INFANT-FEEDING. 



single teeth, and distinct backwardness in their appear- 
ance. Deciduous teeth, commonly called milk-teeth, re- 
main until a child is six years old, when the permanent 
teeth appear. 

Baginsky emphasizes the fact that enough stress is not 
laid on the clinical importance of carious teeth as indi- 
cating tuberculosis and scrofulous conditions. In the sec- 
tion on treatment of rickets I have mentioned the value of 
a nitrogenous diet, especially proteids (albuminoids), to 
aid in the formation of bony structures. The teeth are 
also included in this category. 




Fig. 48. — Two Middle Lower Incisors. Three to 10 
Months; Average, 7 Months. 77 



Thus, when such drugs as glycerophosphate of lime 
or iron and hygienic measures are indicated for the treat- 
ment of rickets they are of especial value where back- 
wardness in teething exists. 



77 1 am indebted to Dr. Dillon Brown for the illustrations, which 
have recently appeared in "The Nursery." 



DENTITION. 



SOI 




Fig. 49. — Nine to 16 Months. Four Upper Incisors. 




Fig. 50. — Two Lateral Lower Incisors and 4 Anterior 
Molars. Thirteen to 17 Months. 



302 



INFANT-FEEDING. 




Fig. 51. — Four Canines. Sixteen to 21 Months. 




Fig. 52. — Twenty-three to 36 Months, although the Average i3 

24 to 30 Months. 



CHAPTEK XLVII. 

Athrepsia Infantum. (Marasmus, or Atrophy; Wast- 
ing Disease, from Malassimilation of Food.) 78 

If infants, when a few months old, suffer with vomit- 
ing or diarrhoea, and this condition is allowed to become 
chronic, then colic and flatulence, associated with con- 
stipation, supervene, and result in a gastro-intestinal ca- 
tarrh. Neglect of this condition means the development 
of the condition known as athrepsia. The infant does not 
thrive, commences to waste, and, unless we realize the 
condition and give the baby proper treatment, such a 
child will die of exhaustion from inanition. "When these 
cases linger for months, they develop rachitis. Recovery 
without treatment is impossible. Parrott was the first to 
define this disease, and classified it into three stages: — ■ 

1. The infant suffers from a simple diarrhoea or loose- 
ness of the bowels. The stools, instead of being bright 
yellow and homogeneous, are liquid, curdy, often of a 
green color, and contain an excessive quantity of mucus. 
The abdomen is distended with gas and remains con- 
stantly in this condition; the tongue is coated and the 
patches of a stomatitis appear in the mouth. The infant 
is restless, constantly whining, and will not sleep at night. 
The milk, being retained, curdles; the tissues become 
flabby, and wasting commences. 

2. The symptoms are intensified and the character- 
istic wasting becomes manifest. The stools, for the most 
part, are loose and frequent, and consist of undigested 
food; they are often pale and putty-like, with a pecul- 



78 Presented to the Section on Diseases of Children, at the 
Fifty-first Annual Meeting of the American Medical Association, 
held at Atlantic City, N. J., June 5-8, 1900. 

(303) 



<jU± ixfaxt-feedixg. 

iar odor. At other times they are dark brown, from the 
presence of altered bile. The infant is most voracious, 
liquid food does not seem to satisfy it, and by thie mis- 
taken kindness of its friends it is fed with some thick 
food, like soft bread, a diet which has the great advantage, 
in their eyes, of keeping it quiet for a longer time than 
liquid food or diluted milk. At times it can hardly be 
made to sleep, or only dozes for a short time, unless under 
the influence of a soothing-syrup applied by its nurse. 
The mouth becomes the seat of a parasitic stomatitis; 
the skin is harsh and dry; small boils or a lichenous rash 
make their appearance. The buttocks and genitals are 
raw and excoriated. The temperature is below normal; 
the feet and hands are congested; the face has a pallid, 
earthy tint; and a sickly lactic-acid smell is given out 
from the body, especially the abdomen. The wasting is 
extreme, the face being shriveled, the skin wrinkled and 
hanging in folds about the thighs and arms. 

3. The third stage brings the child into a moribund 
state. It is too feeble to cry, becomes heavy and drowsy, 
taking little notice of anything. Death then ensues, prob- 
ably preceded by a muscular twitching, strabismus, or gen- 
eral convulsions. 

Henoch does not like the term "athrepsia," intro- 
duced by Parrott, but prefers "atrophy." The first symp- 
tom that this author noticed is that the child's weight 
does not increase; and hence he emphasizes the impor- 
tance of frequently weighing children. He regards the 
weight taken once a week as sufficient, so that it can be 
a determining factor as to the progress made by an infant. 
Henoch says that at the end of the first month the weight 
is increased one-third, at the end of the fifth month it is 
double, and at the end of the twelfth month it should be 
three times the weight at birth. TVeaning, dentition, and 
all other pathological conditions interfere with a proper 
increase in weight. 

By far the greatest number of cases of athrepsia are 



ATHREPSIA INFANTUM. 305 

found in bottle-fed children. There are, however, a great 
many cases to be seen among breast-fed children. We 
can then be positive that the breast-milk is lacking in 
some of its chemical constituents, and frequently we find 
that it is the proteids that are deficient in quantity. If, 
therefore, we meet with a case of athrepsia in a breast-fed 
child, the thing to do is to have a chemical examination 
made of the breast-milk. If the latter is found deficient 
in quality, then we must withdraw it. 

A great many children will be found to thrive at once 
after having been removed from the breasts and changed 
to some artificial mode of feeding, whereas the reverse is 
also true. If, therefore, we wish to do away with its own 
mother's milk, for some positive reason, it is advisable to 
secure a wet-nurse having a child as near as possible the 
age of the one she is to suckle. The hereditary history 
of a nurse is of great importance, as is also the quantity 
and quality of her milk, which should be thoroughly ex- 
amined before she is given this foster-child. 

The treatment of this disease is one which resolves 
itself into removing the cause, and if bad hygienic sur- 
roundings — as impure air, crowded apartments, and im- 
proper diet — are the cause, then these must be remedied 
at once. Medication amounts to nothing in the treatment 
of this disease. 

With hand-fed or bottle-fed children we can easily 
regulate the condition of their bowels, and also easily 
regulate the quality and quantity of the food given 
them. The blandest and least irritating food must be 
selected, while frequent weighing of the infants should 
be resorted to in order to ascertain the progress that is 
being made. 

Where there is much diarrhoea, milk must be used 
sparingly or altogether omitted for awhile, as the hard 
curds formed in the stomach are beyond the weak di- 
gestive powers of the weakened stomach and intestines. 
Small quantities of whey and barley-water, white of egg 

20 



306 INFANT-FEEDING. 

and barley-water, or the juice of a rare chop or steak may 
be given at short intervals during the day and night. 

As soon as the child improves in respect to the diar- 
rhoea, milk in some form may be allowed. Peptonized 
milk is often of much value in these diseases when made 
by mixing 3 ounces of cold milk, adding 2 teaspoonfuls 
of cream, with 1 / 2 of a peptonizing powder, and given 
to the infant after it has stood for fifteen minutes. 

The cream-mixtures are often of much service, such 
as 1 ounce of cream, 3 ounces of barley-water, and 1 tea- 
spoonful of sugar. Every care must be taken that the 
feeding-bottle is clean, and that the food is prepared with 
the most scrupulous neatness. 

The great difference between cows' milk and human 
milk is the fact that human milk is persistently alkaline, 
whereas cows' milk is usually acid; that there is more 
nitrogenous material in cows' milk; that there is a much 
smaller percentage of milk-sugar in cows' milk, and, 
finally, that the nitrogenous constituents of the milk of 
the cow are affected by rennet in a manner different from 
those of mothers' milk. 

In order, therefore, to feed cows' milk to infants, 
these differences must be corrected, and the correction 
of them causes further differences, which have, in turn, 
also to be corrected; the process, therefore, is a compli- 
cated one. 

Before considering the means adopted to alter the 
chemical composition of cows' milk, it would be proper 
to state that there is a common, but false, belief that 
milk from one cow is the best for infants' use. The 
principle that underlies this belief is perfectly right. It 
is, that it is desirable to obtain milk of uniform compo- 
sition; but it has been found experimentally that milk 
of the same cow varies in its composition during twenty- 
four hours, and that it is, in reality, more likely that a 
mixture of the milk from several cows will show a more 
constant analytical result than that from one single ani- 



ATHREPSIA INFANTUM. 307 

mal. Jacobi and others have stated that the chances of 
infection from tuberculosis through the medium of milk 
can only be lessened by feeding from a large number of 
cows. 

In order to render the character of cows' milk similar 
to that of human milk, it is necessary to reduce the amount 
of casein in cows' milk. This is usually done by treating 
the milk with water, thus diluting it ; but sometimes lime- 
water is used, for the reason to be stated immediately. 

Second, the proportion of fat in cows' milk is less 
than in human milk, and it has been still further reduced 
by dilution. Therefore, it is necessary to add to it fat in 
some form or other, and this is commonly done by adding 
cream. 

Thirdly, sugar must be added to cows' milk in order 
to bring the lactose up to the proper level. It has been 
held by some that it is necessary to use milk-sugar for 
this purpose, but there seems to be little doubt that cane- 
sugar will serve the purpose quite as well, or even better. 

In the fourth place, according to Jacobi, it is neces- 
sary to prevent as far as possible the great coagulating 
effect that the ferment of the infants' gastric juice has 
on the casein of cows' milk, and this is satisfactorily ac- 
complished by adding an alkali, such as lime-water, or 
some mucilaginous material, such as barley-water. In 
this way the casein curd is rendered loose and flocculent 
and more like that of human milk. 

Dr. Meigs, of Philadelphia, advises the preparation 
of the following mixture: Cream, 2 ounces; milk 1 
ounce: lime-water, 2 ounces; sugar- water, 3 ounces; the 
latter is made by dissolving about 2 1 / 4 ounces of milk- 
sugar in a pint of water. 

Condensed cows' milk is simply coays' milk that has 
been evaporated to one-fourth of its volume and sterilized, 
nothing at all being added to it. Then, again, there is a 
form in which the milk is not only condensed, but has 
also the addition made to it of about 50 per cent, of cane- 



308 INFANT-FEEDING. 

sugar. When it is also borne in mind that the composi- 
tion of condensed milk varies with the season of the year, 
great fluctuations must occur in its chemical constitution. 

Condensed milk must also be diluted with water be- 
fore it is fit for use, and this dilution may entirely dis- 
arrange the proportion of the component parts of the 
fluid. For this reason it is found that even where infants 
appear to thrive on condensed milk, their apparent good 
health is due to an excessive deposit of fat, and not to a 
sufficient supply of albuminoids; and they are, in the 
long run, more prone to disease than babies fed on the 
breast or on cows' milk properly prepared. 

The above remarks apply with less force to that va- 
riety of condensed milk which is made from sterilized 
fluid and then sweetened; but even this preparation re- 
quires for digestibility to be diluted some ten times, and 
this reduces its nutritive value to a dangerous degree. 

At times we must resort to various methods of feed- 
ing, until we find the method on which a baby will thrive, 
and so it is that we have: (1) humanized milk, (2) steril- 
ized milk, (3) pasteurized milk, and (4) peptonized milk. 

1. Humanized milk is simply cows' milk diluted with 
a certain amount of whey and with some cream. It is 
prepared in the following way: A pint of milk is set 
aside in a cool place until the cream rises to the surface. 
This is skimmed off and kept, and to the milk remaining 
is added enough rennet to curdle it thoroughly. The 
whey is strained off from the curd and added with the 
cream, previously separated, to a pint of fresh cows' milk, 
and the mixture, is known as humanized milk. It is dis- 
tinctly more digestible than ordinary diluted milk, and 
often agrees well with young infants, being given with- 
out any further dilution, in quantities suitable to the age 
of the infant. It may be employed exclusively during 
the first three months of the infant's life, and after that 
age may be used in combination with some farinaceous 
food. 



ATHREPSIA INFANTUM. 309 

2. Sterilized rnilk is that in which all germs tending 
to decompose it have been destroyed by exposure to a 
boiling heat at a temperature of 212° F. for a short 
period of time: from 15 to 45 minutes. Fresh cows' 
milk always contains impurities received from the cow 
or the atmosphere or from the vessels in which it is con- 
tained, though much care may have been taken to main- 
tain absolute cleanliness. The milk is usually exposed 
to the action of steam or in a boiling heat from 15 to 45 
minutes, and will keep about 24 hours. A fresh bottle 
must always be opened for each meal; if anything is left 
in the bottle after the baby has finished, it must be thrown 
out. 

3. Pasteurized milk is simply steamed at a tempera- 
ture of 140° to 170° F., for about 30 minutes; in other 
words, it is really sterilized milk at a lower temperature. 

4. Peptonized milk, the fourth substitute for ordi- 
nary diluted milk, is as simple a preparation as sterilized 
milk. It consists of milk which has previously been par- 
tially digested by the addition of some preparation of a 
digestive ferment, among the best known of which are 
Benger's liquor pancreaticus, Fairchild's peptonizing pow- 
ders, etc. The milk should be diluted to some extent 
before being peptonized; but it is not necessary to dilute 
to such an extent as has been recommended for ordinary 
cows' milk. Generally, even for an infant two or three 
days old, the addition of an even quantity of barley-water 
will be sufficient, and, when a baby is two or three months 
old, a dilution of 2 parts of milk with 1 part of water will 
be digested with comfort. 

In France there is a law forbidding anyone to give 
solid food of any kind to infants under a year without 
the written authority of a qualified medical man. 

Jacobi says : "Whatever I have here brought forward 
is certainly not to disparage the boiling of the milk; it 
is to prove the danger of relying on a single preventive 
when the causes of intestinal disorders are # so many." It 



310 INFANT-FEEDING. 

is true, however, that the large majority of the latter de- 
pends on causes which may be met by sterilization, but 
not by sterilization only; also by pasteurization, that is, 
heating the milk to 70° C. (165° F.), and keeping it at 
that uniform temperature for 30 minutes: a procedure 
which destroys the same serais that are killed bv a more 

i/O t/ 

elevated temperature, without much change in flavor and 
taste. 

One of the questions connected with the employment 
of sterilized or pasteurized milk is this: whether the milk 
to be used for a child ought to be prepared at home, or 
whether the supply may be procured from an establish- 
ment where large quantities of milk believed to become 
immutable by sterilization for an indefinite period are kept 
for sale. In regard to this problem Fliigge plainly ex- 
presses his regrets that "we have allowed ourselves to be 
guided by people who are neither hygienists nor physi- 
cians, but chemists, farmers, or apothecaries, and whose 
actions have been based on three false beliefs. Of these 
the first is that boiling for three-quarters of an hour de- 
stroys germs; the second that whatever bacteria remain 
undestroyed are innocuous, and the third, that proliferat- 
ing bacteria can always be recognized by symptoms of 
decomposition." Nothing is more erroneous. Soxhlet 
himself, the German originator of sterilization, knew at 
an early time that the fermenting process is now and then 
but partially interrupted by boiling, that butyric acid may 
be found in place of lactic acid, that a strong evolution 
of gas may be caused after much boiling, and that such 
milk may give rise to flatulency. Aye, milk which hap- 
pens to contain the resistant spores of bacteria becomes 
a better breeding-ground for them by the very elimina- 
tion of lactic acid, and the longer such sterilized milk is 
preserved and offered for sale, the worse is its condition. 
It may be true that these conditions are not met with very 
frequently, but an occasional single death in a family 
caused by poisonous milk will be more than enough. 



ATHREPSIA INFANTUM. 311 

Therefore, the daily home-sterilization is by far preferable 
to the risky purchase from wholesale manufacturers who 
cannot guarantee, because, in the nature of things, they 
cannot know, the condition of their wares. 

Another alteration of a less dangerous character, but 
far from being desirable, is the separation of cream from 
sterilized milk which is preserved for sale. Renk 79 found 
it to take place to a slight extent during the very first 
weeks, but later to such a degree that 43.5 per cent, of 
all the cream contained in the milk was eliminated. 

Sterilization has been claimed to be no unmixed boon, 
because of its changing the chemical constitution of milk. 
Still, the opinions on that subject vary to a great extent, 
the occurrence of changes being both asserted and denied 
by apparently competent judges. But what I have said 
a hundred times is still true and borne out by facts, viz. : 
that no matter how beneficial boiling, or sterilization, or 
pasteurization may be, they cannot transform coavs' milk 
into woman's milk, and that it is a mistake to believe that 
the former, by mere sterilization, is a full substitute for 
the latter. It is true that when we cannot have woman's 
milk we cannot do without cows' milk. There is no 
alleged substitute that can be had with equal facility or 
in sufficient quantity. But after all it is not woman's 
milk. Babies may not succumb from using it, and may 
seldom appear to suffer from it; indeed, they will mostly 
appear to thrive on it, but it is a make-shift after all, and 
requires modifications. Hammarsten was the first to prove 
the chemical difference between the casein of cows' milk 
and of woman's milk. Whatever was known on that sub- 
ject at that time I collated in Gerhardt's "Handbuch der 
Kinderk.," vol. i, 1875 (second edition, 1882). But lately 
Wroblewski demonstrated the difference in solubility of 
the two milks. Woman's casein retains, during pepsin di- 
gestion, its nuclein — proteid rich in phosphorus — in solu- 



Arcliiv fur Hygiene, xvii. 



312 INFANT-FEEDING. 

tion, which is fully digested; in cows' casein the nuclein 
is not fully digested, — a "paranuclein" is deposited un- 
dissolved and undigested. 

Henry A. Bunker, in an article on the modification 
of cows' milk, says that the difficulty of the digestion of 
the casein of cows' milk in some children has seemed to 
be the resistance to the infant's digestive powers, even 
after the partial hydration supposed to be brought about 
by hydrochloric acid and heat. In all such cases the fa?cal 
evacuations were white, hard, and dry, such as occur so 
often on a plain, sterilized-milk diet. In many of these 
cases, these dry, scybalous masses would frequently set 
up mucous diarrhoea and give rise to severe colicky pains. 

The only evidence of partial hydration by the acid 
and heat would seem to be the fact of increased nutri- 
tion in spite of these difficulties. Professor Chittenden 80 
maintains, and proves by a beautiful laboratory experi- 
ment, that the products of gastric digestion have the power 
of combining with more hydrochloric acid than the orig- 
inal proteid, for, as soon as proteolysis commences, the 
products so formed begin to show their greater affinity for 
acid by withdrawing acid from its combination with the 
native proteid : a supposition which is necessary to account 
for even the starting of the proteolytic process. Further, 
it is evident that proteoses and peptones combine with 
a far larger equivalent of acid than the native proteid- 
albumin, in the experiment. This, doubtless, depends 
upon the cleavage of the large proteid molecule into a 
number of smaller or simpler molecules, each of the latter, 
perhaps, combining with a like number of hydrochloric- 
acid molecules. However this may be, it is evident that 
the products of pepsin-proteolysis combine with a larger 
amount of hydrochloric acid than the mother-proteid, and 
that the transformation of the latter, at least under the 
conditions of the experiment, is a slow and gradual process. 



80 "Cartwright Lectures on Digestive Proteolysis," 1894. 



ATHREPSIA INFANTUM. 313 

It will be remembered that the original method pro- 
posed the hydration of the milk-proteids by hydrochloric 
acid and a rather prolonged boiling. Twenty drops of a 
10-per-cent. hydrochloric-acid solution were added to 1 
pint of water and 1 quart of milk, and this mixture was 
to be kept at boiling temperature for about twenty min- 
utes. The addition of a larger amount of the acid, unless 
the milk was quite fresh, was found to result quite fre- 
quently in curdling the milk. It was also found that the 
acid so added, up to the point of saturation or breaking, 
exists as combined acid, as was evident from the failure of 
reagents to show free hydrochloric acid in the completed 
mixture. 

The indications that the hydration secured by this 
method is not always sufficient to meet the requirements 
of certain infantile stomachs, and the fact that usually in 
such cases the nutrition is increased in spite of incomplete 
and painful digestion, seemed so strongly confirmatory of 
the results of Professor Chittenden's researches, that I 
determined to copy, in part, his experiments on HC1 
saturation, as applied to the proteids of milk. 

To this end, milk was prepared in the original way, 
except that the 20 drops of dilute hydrochloric acid were 
added in 1 / 2 , instead of 1, pint, watery solution, and 
slowly, but intimately, mixed with 1 quart of milk. This 
mixture was brought as rapidly as possible to the boiling 
temperature and then set aside until another half-pint of 
water was prepared with 20 drops more of the acid. This 
was added to the previously boiled milk and acid, stirred 
thoroughly, and again brought to the boiling-point. The 
result thus obtained was a thoroughly palatable milk, with 
no taste of having been boiled, and gave no indication of 
free hydrochloric acid with Gunzberg's reagent. Ru- 
disch's plan is similar to the latter. 

Proteids in excess are indicated by the presence of 
curds in the stools. This is the most frequent cause of 
colic in infants. Sometimes there is diarrhrea, more often 



314 INFANT-FEEDING. 

constipation when the proteids are in excess. The excess 
of proteids frequently causes vomiting and so does an 
excess of either fat or sugar. If, therefore, after reducing 
the percentage of proteids, fat, or sugar, vomiting still 
persists, then we must feed the baby with smaller quan- 
tities. Thus, we may have to give a 4-ounce bottle where 
a 6-ounce or a 5-ounce feeding causes vomiting. Certain 
rules can be laid down: if an infant does not thrive, — 
that is, does not gain in weight without showing any signs 
of indigestion, — then the proportions — i.e., percentages of 
all ingredients — should be gradually increased; chiefly 
the proteids, however, for the latter is the most important 
element in an infant's food. 

An infant soon after birth was put on modified milk, 
containing : — 

Fat 2.00 

Milk-sugar 5.00 

Albuminoids 0.75 

Lime-water Vie 

I ordered eight feedings, 2 ounces in each. As the 
child was constipated, we soon after increased the formula 
to the following percentages: — 

Fat 2.50 

Milk-sugar 6.00 

Albuminoids 1.00 

Lime-water Vie 

As the stools did not change, the fat was increased 
to 3 per cent., other ingredients the same. The child 
gained but 3 ounces in weight in five weeks; had green- 
ish, curded stools, and had distinct evidence of intestinal 
indigestion. It also vomited curds. The general condi- 
tion of the child was one of extreme irritability, with very 
little sleep. Hand-feeding was stopped. The child's ali- 
mentary tract was thoroughly cleaned, and a wet-nurse 
secured. This happened when the baby was six weeks 



ATIIREPSIA INFANTUM. 315 

old; the child nursed well, gained 6 ounces the first week, 
8 ounces the second, and weighed 14 pounds when it was 
four and a half months old. The child improved until it 
was seven months old, when suddenly the weight remained 
stationary. A specimen of breast-milk was sent to John 
S. Adriance, the chemist of the Nursery and Child's Hos- 
pital, who found the .following percentages: — 

Fat 2.000 

Sugar 7.431 

Proteids 0.882 

Ash 0.162 

Specific gravity, 1031; reaction, alkaline. 

It is very evident that the deficiency in albuminoids 
or proteids was accountable for the stationary weight. The 
child did not gain an ounce in one month. We discharged 
the wet-nurse, and resorted to hand-feeding, when the 
child's general condition changed, and she is bright and 
well to-day. 

In another instance, a child had been nursed by its 
own mother for three months, and had gained in weight 
regularly at the rate of 6 and 7 ounces per we'ek; the 
stools were normal in quantity and quality, when sud- 
denly the child appeared to be colicky, was restless at 
night, had green stools, and did not appear to thrive. For 
two consecutive weeks the child did not gain in weight, 
and a specimen of breast-milk was sent to the Pediatrics 
Laboratory. Mr. R. W. Bailey, the chemist, examined 
the specimen, with the following result: — 

Fat 2.43 

Proteids 1.25 

Sugar 6.51 

Ash 0.20 

Total solids 10.39 

Specific gravity, 1027; reaction, slightly alkaline. 



316 INFANT-FEEDING. 

The percentage of fat and proteids is so low that it 
was very plain to me why this child did not increase in 
weight. On putting the child on an oatmeal and top- 
milk mixture, the digestion improved, the child's sleep 
was better, and the weight increased. 

Another case was that of a nursling, brought to me 
with a history of excessive crying, greenish stools, cheesy 
curd in the stools, vomiting, restlessness, and a general 
condition of malassimilation; I asked for a specimen of 
breast-milk, which Mr. Bailey kindly examined, with the 
following result : — 

Fat 4.32 

Sugar 6.22 

Proteids 1.80 

Ash 0.19 

Total solids 12.53 

Reaction, neutral. 

The general history of the case showed that the child 
was fed every time it cried, and thus it was evident that 
overfeeding was the real cause of the trouble in this case, 
for I learned that the child frequently nursed for hours 
at the breast, and was also allowed to go to sleep with the 
nipple in its mouth. Whenever the child cried it was fed, 
frequently as often as every half-hour, so that in this case, 
while the quality of the breast-milk was absolutely nor- 
mal, as demonstrated by the chemical examination, it re- 
quired only the judicious interval for feeding to give the 
child's stomach proper time for the assimilation of its 
food. 



CHAPTEK XLVIIL 

IxFANT-FEEDIXG IN SUMMER CoMPLAIXT. 

The successful managemeut of a case of summer com- 
plaint affecting the stomach and bowels depends largely 
on the feeding. We know that when food is given which 
is improper in quality or quantity, — in other words, when 
dietetic errors have been committed, — then the child will 
suffer with gastro-intestinal or gastric disorders. The 
nursing baby, fed exclusively from the breast, is usually 
exempt from summer complaint, unless it is fed irregu- 
larly or if the milk is of an improper quality. Thus we 
know that, when breast-milk contains large quantities of 
colostrum-corpuscles, such milk has a decided laxative 
effect. What has already been said in regard to the proper 
supervision of breast-milk, in the chapters on "Breast- 
feeding" and "Wet-nursing," must be emphasized when 
it is desired to feed an infant during the summer months. 

The depressing effect of extreme heat in midsummer 
naturally tends to lower the vitality of the infant. We 
must not, therefore, be surprised to find that an appetite, 
which has been unusually good heretofore, suddenly di- 
minishes. When the infant shows loss of appetite, noth- 
ing will tone up the stomach and bowels more quickly 
than a sudden change of air from the city to the sea- 
shore. If, in spite of the change of air to the sea-shore, 
the infant still continues to vomit or to have loose, green- 
ish, or "muddy" stools (the latter are usually found in 
that most frequent form of summer complaint known as 
"colitis"), then the breast-feeding should be stopped and 
the stomach given complete rest for twenty-four or forty- 
eight hours. Substitute food such as barley-water, rice- 
water, albumin-water, or weakened mixed tea to which 

(317) 



318 INFANT-FEEDING. 

the white of a raw egg has been added; Inese can be given 
in teaspoonful doses. Steak-juice can also be advanta- 
geously given at regular intervals of every three to four 
hours. In this manner we remove milk from our dietary, 
for the time being, and give the above liquid nourish- 
ment, which is easily absorbed. It is a good plan to 
dextrinize all the cereals, if the child shows a tendency 
toward vomiting after the milk has been withdrawn. 
When severe vomiting persists, in spite of the withdrawal 
of milk and the substitution of the cereals and the white 
of egg above mentioned, then absolute rest of the stomach 
must be insisted upon and rectal feeding substituted there- 
for. 

RACAHOTJT POWDER. 

1 pound of rice-powder. 2 ounces of arrowroot. 

1 ounce of powdered salep. 2 ounces of sugar of milk. 

1 pound of cocoa. 1 vanilla-bean. 

1 pound of confectioners' xxx sugar. 

Mix and thoroughly rub together, put into glass jars, and 
fasten. Boil 1 teaspoonful with 4 ounces of water. Feed every three 
or four hours. 

RECTAL ALIMENTATION. 

Always cleanse the rectum by using an enema of 
soap-water or glycerin and water, in the proportion of 4 
ounces of glycerin to a pint of warm water, at a tempera- 
ture of 100° F. Following this rectal cleansing, pepto- 
nized milk "thoroughly peptonized," or yolk of an egg 
with starch-water, or beef-blood and starch-water, should 
be slowly injected. More than 2 ounces should not be 
used for one feeding enema. This method of feeding has 
already been described in the chapter on the "Feeding of 
Diphtheria-Intubation Cases." 

DIETETIC MANAGEMENT OF A BOTTLE-FED BABY. 

Discontinue all kinds of food which were given at 
the beginning of the summer complaint. For example, if 



INFANT-EEEDING IN SUMMER COMPLAINT. 319 

milk lias been given, it must be discontinued, and in its 
place a food which is more easily assimilated must be 
supplied. Such foods are barley-water, rice-water, farina- 
water, sago-water or arrowroot-water. These are very 
easily made by adding a tablespoonful of either one of 
the above-mentioned cereals to a pint of water and boil- 
ing the same for about one-half hour; strain through a 
cheese-cloth, and then add enough water to make 1 pint. 
This proportion will keep as a stock solution for one or 
two days, if put into a refrigerator. In hot weather pre- 
pare daily. 

In feeding we use 3 to 6 ounces, to which a pinch of 
salt and some sugar have been added, and warm the same 
to body-heat immediately before feeding. In making rice- 
water a much longer time is required to boil the same. 
For further particulars we refer to the dietary. The 
quantity to be fed depends on the age of the child; thus, 
if the child has received 6 ounces of milk at one feeding, 
prior to its attack of summer complaint, then a good plan 
is to substitute 6 ounces of barley-water, rice-water, or 
sago-water for the 6 ounces of milk. It is also a good 
plan to allow a larger feeding interval during an attack 
of summer complaint, and to give the stomach and bowels 
less work. Hence my plan has been to feed every four 
hours, if the interval prior to the attack has been every 
three hours. 

Thirst requires careful management. If the child is 
very thirsty it is a good plan to give plain boiled water, 
or to add the white of a raw egg ("albumin-water"). If 
the child is over one year old, a few drops of expressed 
meat-juice, made by broiling a steak over a fire and ex- 
pressing the juice in a lemon-squeezer or meat-press, is 
advantageous. When the infant's condition is normal 
and its digestive power is strengthened, then we can grad- 
ually return to Nature's remedy, namely: milk-feeding. 

Every physician knows how difficult it is to keep milk 
fresh and pure during the hot weather, and, therefore, 



320 INFANT-FEEDING. 

in summer it is advisable to pasteurize or sterilize the 
milk for about fifteen minutes, as soon as it is received 
from the dairy, and then to keep it in the refrigerator 
until it is time for feeding. Thus we prevent not only 
the formation of the germs, but also the development of 
toxins, which are so death-dealing in midsummer. 

The most vital point to be considered in the man- 
agement of summer complaint, next to the diet, is fresh 
air, and hence, unless children can be given the benefit of 
daily excursions to the sea-shore or to the mountains, and 
can be removed from unsanitary and improper hygienic 
surroundings, we must not look for permanent results. 

NURSING INFANT. 

If a nursing infant has summer complaint, then it is 
advisable to stop nursing. Frequently giving the stom- 
ach absolute rest for one-half or one whole day will work 
wonders. 

The breast-milk should be drawn with the aid of a 
breast-pump at regular intervals, as though the baby were 
nursing, and the milk should be thrown away. The same 
rule applies to the nursing baby as applies to the bottle- 
fed baby. Thus milk must be temporarily withdrawn 
and other feeding substituted. 



DIETAKY. 

Almond-milk. 

Take 2 ounces of sweet almonds, scald them with 
boiling water; after a few moments express them from 
the hulls; then pour the hot water away. Put the 
blanched almonds into a mortar and pound them thor- 
oughly, and add either 2 ounces of milk or 2 ounces of 
plain water. After this is thoroughly mixed, it is to be 
strained through cheese-cloth, and the strained liquid will 
be the almond-milk. 

Keller's Halt-soup. 

Take of wheat-flour 50.0 (about 2 ounces). To this 
add 11 ounces of milk. Soak the wheat-flour thoroughly, 
and rub it through a sieve or strainer. 

Put into a second dish 20 ounces of water, to which 
add 3 ounces of malt-extract; dissolve the above at a tem- 
perature of about 120° F., and then add 10 cubic centi- 
metres (about 2 1 / 2 drachms) of 11-per-cent. potassium 
bicarbonate solution. Finally mix all of the above ingre- 
dients, and boil. 

This gives a food containing: — 

Albuminoids 2.0 per cent. 

Fat 1.2 per cent. 

Carbohydrates 12.1 per cent. 

There are in this mixture: — 

Vegetable proteids 0.9 per cent. 

The wheat-flour is necessary, as otherwise the malt- 
soup would have a diarrheal tendency. The alkali is 

21 (321) 



322 INFANT-FEEDING. 

added to neutralize the large amount of acid generated 
in sick children. Biedert emphasizes the importance of 
giving fat, rather than reducing its quantity, in poorly 
nourished children, and cites the assimilability of his 
cream-mixture or of breast-milk in under-fed children as 
proof of his assertions. The author has used this malt- 
soup most successfully in the treatment of athrepsia 
(marasmus) cases in which the children were simply 
starved. 

Junket of Milk and Egg. 

Beat 1 egg to a froth and sweeten with 2 teaspoonfuls 
of white sugar. Add this to 1 / 2 pint of warm milk; then 
add 1 teaspoonf ul of essence of pepsin (Fairchild) ; let it 
stand till it is curdled. The above is useful in typhoid 
and similar wasting diseases. 

Plain Junket. — This is sometimes called "curds and 
whey.". Take 1 / 2 pint of fresh, raw milk, and heat it 
lukewarm. Then add a teaspoonful of Fairchild's essence 
of pepsin, and stir the mixture thoroughly. Pour into 
custard cups, and let it stand until firmly curdled. The 
flavor can be improved by adding some essence of lemon 
or cinnamon or grated nutmeg. 

When the essence of pepsin (Fairchild's) cannot be 
had, or for convenience in traveling, the author has used 
Hansen's junket tablets, which will give similar results 
as the liquid essence of pepsin. 

Peptogenic Milk-powdee. 

The pancreas ferment trypsin is known to have a 
remarkable affinity toward milk, digesting its casein with 
great rapidity without altering its other elements, and 
without rendering the milk repulsive. When milk is so 
treated it is known as peptonized milk. Through the ex- 
pert investigation of the well-known chemist Dr. Albert 
Leeds, the peptogenic milk-powder was found to yield a 
milk which was similar to a humanized milk. The author 



DIETARY. 323 

has had some experience in the modification of cows' milk 
by the addition of peptogenic milk-powder, and can safely 
say that it is one of the most valuable additions to onr 
infant-feeding that we possess. 

There are three steps necessary for the preparation 
of "humanized milk" in rising the peptogenic milk- 
powder: — 

1. To prepare — with peptogenic powder, cows' milk, 
water, and cream — a mixture which has the quantitative 
composition of average human normal milk. 

2. To subject this mixture to the action of the di- 
gestive principle by which the albuminoids (casein, etc.) 
are converted into such form as to become identical with 
those of human milk. 

3. To then destroy the digestive ferment by simply 
raising the temperature of the milk to the boiling-point. 
This heat also destroys the bacteria, and renders the milk 
practically sterile during the time required for its use: 
twenty-four hours. 

DIRECTIONS FOR "HUMANIZED MILK." 

No. 1. — For the daily food of a healthy infant: Put 
into a clean graniteware or porcelain-lined saucepan one 
measure (which accompanies each bottle) of peptogenic 
powder; add to this 1 / 2 pint of cold water, 1 / 2 pint of 
cold, fresh milk, and 4 tablespoonfuls of cream. Place 
the saucepan on a hot range or gas-stove, and heat, with 
constant stirring, until the mixture boils. The heat should 
he so applied as to make the milk toil in ten minutes. 
Keep in a clean, well-corked bottle, in a cool place. When 
needed, shake the bottle, and pour out the desired por- 
tion, and warm the same before feeding. 

No. 2. — Specially designed for children with feeble 
digestion, or when the stomach and bowels are disordered, 
as in catarrhal conditions. Put into a clean bottle 1 meas- 
ure of the peptogenic powder, 1 / 2 pint of cold water, 1 / 2 
pint of cold, fresh milk, and 4 tablespoonfuls of cream. 



324 INFANT-FEEDING. 

Shake well, place the bottle in a pail or tin kettle of water, 
holding a gallon, as hot as can be borne by the hand 
(115° F.), and keep the bottle there for thirty minutes. 
Then pour all into a saucepan, and quickly heat to boiling- 
point, with constant stirring. The bottles of the pepto- 
genic milk-powder made by Fairchild Brothers & Foster 
have a metal screw-cap, which is the measure above al- 
luded to. If the infant's digestive powers are still weaker, 
or if, after feeding the last-named formula, vomiting 
takes place, then it is safer to use: — 

One measure of peptogenic milk-powder. 
One-third pint of raw milk. 
Two-thirds pint of water. 

Mix, heat, and boil, as described above, and it is ad- 
visable to feed at longer intervals; for example, every 
three or four hours, if the infant has previously been fed 
every two or three hours. Never use the balance left over 
in a feeding-bottle after the infant has sucked, but al- 
ways give a fresh' quantity of food for each meal, and 
whatever the baby leaves should be invariably thrown 
away. 

The weight and the stools are important factors in 
judging when to increase the quantity of milk and cream, 
or vice versa. 

Peedigested Food. 

To Prepare Bice. — Take 1 / 4 pound of rice, add water, 
and boil until soft. Break grains by passing through a 
colander. Take, of bana-diastase (American Ferment 
Company), 8 grains, and dissolve in 1 ounce of water 
and add to the rice, which must be kept warm, but not 
hot. Let stand for two hours at a temperature of 105° 
F. When rice is thoroughly softened, season with salt, 
sparingly. Add a little cream if desired. Serve hot or 
cold. 

To Prepare Beans or Peas. — Take 1 / i pound of 
beans or peas, add water, and boil until soft. Remove 



DIETARY. 325 

skins by passing through, a colander. Take of caroid 
powder, 4 grains, and of bana-diastase, 8 grains; dissolve 
in 1 ounce of water. Add to the beans, which must be 
kept warm, but not hot. Let stand for one hour at a 
temperature of 105° F. Season slightly with salt. Beans 
and peas require the double action of proteolytic and 
starch-converting ferments, as they are composed largely 
of proteids, as well as starch. 

Peptonized j\Iilk:. 

Into a clean, quart bottle put the powder contained 
in one of the Fairchild peptonizing tubes, and a teacupf ul 
(gill) of cold water; shake, then add a pint of fresh, cold 
milk, and shake the mixture again. Place the bottle in 
water as hot as the whole hand can be held in it with- 
out discomfort. (About 115° F.) 

Keep the bottle there five or ten minutes as directed. 

At the end of that time put the bottle on ice at once 
to check further digestion and keep the milk from spoil- 
ing. 

Place the bottle directly in contact with the ice. 

The degree of digestion is very simply regulated by 
the length of time in which the milk is kept warm. 

PARTIALLY PEPTONIZED MILK. 

Put into a clean agateware or porcelain-lined sauce- 
pan the powder contained in one of the Fairchild pep- 
tonizing tubes, and a teacupf ul (gill) of cold water; stir 
well; then add a pint of cold, fresh milk. Heat with con- 
stant stirring until the mixture boils. The heat should 
be so applied that the milk will come to a boil in ten min- 
utes. When cool, strain into a clean bottle, cork well, and 
keep in a cold place. AYhen needed, shake the bottle, 
pour out the required portion, and serve cold or hot, as 
directed by the physician in charge. Milk so prepared 
will not become bitter. 



326 INFANT-FEEDING. 

IMMEDIATE PROCESS. 

Put 2 tablespoonfuls (1 ounce) of cold water in a 
goblet or glass; dissolve in this one-fourth of the contents 
of a peptonizing tube; add 8 tablespoonfuls (4 ounces) 
of warm milk; drink immediately, sipping slowly. 

If half a pint of milk is required, double the propor- 
tions of water, peptonizing powder, and milk. 

COLD PROCESS. 

Into a clean, quart bottle put the powder contained 
in 1 of the Fairchild peptonizing tubes, and a teacupful 
(gill) of cold water; shake, then add a pint of fresh, cold 
milk; shake the mixture again and immediately place the 
bottle on ice, without subjecting it to the water-bath or 
any heat. Place the bottle directly in contact with the 
ice. 

When needed, shake the bottle, pour out the required 
portion, and use in the same manner as ordinary milk. 

Peptonized Milk-gruel. 

Thick, well-boiled, hot gruel 1 / 2 pint. 

Milk, fresh, cold V 2 pint. 

Mix and strain into a small pitcher or jar, and im- 
mediately add the contents of 1 Fairchild peptonizing 
tube; mix well. Let it stand in the hot water-bath, or 
warm place, for five minutes, then put in a clean bottle 
and place on ice. Serve hot or cold. 

Gruel made from arrowroot, flour, barley, oatmeal, 
etc., will serve for the purpose. In each instance the 
farinaceous material should be boiled with water until 
the starch-granules have been thoroughly swollen, broken 
up, and incorporated with the water. 

Whey. 

To make whey take 1 / 2 pint of fresh milk, heated 
lukewarm, not warmer than can be agreeably borne by 



DIETARY. 327 

tlie mouth (about 115° F.); add 1 teaspoonful of Fair- 
child's esseuce of pepsin, and stir just enough to mix. 
Pour into custard-cups; let it stand until firmly curdled; 
then beat up with a fork until the curd is finely divided; 
now strain, and the whey is ready for use. 

Whey prepared from fresh cows' milk should be alka- 
line and contain 

From 0.8 to 1 per cent, of laetalbumin. 
0.03 per cent, of casein. 
1.0 per cent, of fat. 

When such whey is added to milk for an infant under 
6 weeks take, of whey, 2 parts; milk, 1 part. This can 
be increased until equal parts of milk and whey are used 
for a child several months old. 

Preparation of Siueet Whey. — Sweet whey is best 
made by the following method: For each pint of whey 
needed take 1 pint of whole fresh milk or fat-free milk, 
heated to 37.7° C. (100° F.), and add 8 cubic centime- 
tres (2 drachms) of the essence of pepsin or some of the 
preparations of liquid rennet. This will precipitate the 
casein in the form of a curd, which is then broken up 
with a fork; the fluid which remains is the whey. This 
is strained through two thicknesses of boiled cheese-cloth 
and one thickness of absorbent cotton and slowly cooled 
to a temperature of 10° C. (50° F.), and kept on ice 
until needed. If the whey is to be mixed with cream, 
it must first be heated to 65.5° C. (150° F.), in order to 
kill the rennet enzyme. Whey mixtures should not be 
heated above 68.3° C. (155° F.) if one wishes to keep 
safely under the coagulation-point of the laetalbumin. 

Junket (Curds and Whey). 

Junket. — Take 1 / 2 pint of fresh milk, heated luke- 
warm — not warmer than can be agreeably borne by the 
mouth (about 115° F.); add 1 teaspoonful of Fairchild's 



328 INFANT-FEEDING. 

essence of pepsin, and stir just enough to mix. Pour into 
custard-cups; let it stand until firmly curdled; may be 
served plain or with sugar and grated nutmeg. 

An egg beaten to a froth and sweetened with 2 tea- 
spoonfuls of sugar may previously be added to the half- 
pint of milk, forming a highly nutritious and smooth jelly. 
The essence will curdle milk with egg as readily as plain 
milk. 

Whey. — Curdle warm milk with the essence of pep- in 
as above directed; then beat up with a fork until the curd 
is finely divided; now strain, and the whey is ready for 
use. 

TVliey is a highly nutritious fluid food peculiarly use- 
ful in many ailments and always valuable as a means of 
variety in diet for the sick. It is frequently resorted to 
as a food for infants to tide over periods of indigestion, 
summer cemplaints, etc. 

Gum-Aeabic TVatee. 

Dissolve 1 ounce of gum arabic in a pint of boiling 
water; add 2 tablespoonfuls of sugar, a wineglassful of 
sherry, and the juice of a large lemon. Cool and add ice. 

Lime-water. 

Pour 2 quarts of water over fresh unslaked lime the 
size of a walnut; stir until slaked, and let stand until 
clear; then bottle. Lime-water is often ordered with 
milk to neutralize acidity of the stomach. 

T AM AEIXE-WATEE . 

A very refreshing drink may be made by adding 1 
pint of hot water to 1 tablespoonful of preserved tama- 
rinds, and setting aside to cool. 

Lemoxade. 

Squeeze the juice from 1 lemon. Add 2 tablespoon- 
fuls of sugar and 1 cup of water. Strain and serve. 



DIETARY. 329 

Milk and Albumin. 

Put into a clean quart bottle 1 pint of milk, the 
whites of 2 eggs, and a small pinch of salt. Cork and 
shake hard for five minutes. 

Milk-punch. 

Take 1 / 2 pint of fresh, cold milk and add 2 teaspoon- 
fuls of sugar, and stir well until dissolved; then add 1 
ounce of either brandy or sherry wine. 

Orangeade. 

Substitute orange-juice for that of lemon in the recipe 
for "Lemonade." 

Tea. 

Scald out the teapot and put in the tea, using 1 tea- 
spoonful for 1 cupful. Pour on hotting water, and let 
teapot stand four or five minutes. If allowed to stand 
too long, the tannin in the tea is developed, which not 
only darkens the tea, but also renders it hurtful. 

Albumin- water. 

Stir the whites of 2 eggs into 1 / 2 pint of ice-water, 
without beating; add enough salt or sugar to make it 
palatable. 

Apple-water. 

Slice into a pitcher 1 / 2 dozen juicy sour apples; add 
1 tablespoonful of sugar, and pour over them 1 quart of 
boiling water. Cover closely until cold; then strain. 

Toast-water. 

Equal measures of stale bread, toasted, and boiling 
water. Cut the bread in thin slices, put into pan, and 
dry thoroughly in a slow oven until crisp and brown. 
Break in pieces, add water, and let stand one hour. Strain 
and season. Serve hot or cold. 



330 INFANT-FEEDING. 

B ARLE Y-W ATER. 

"Wash 2 ounces (wineglassful) of pearl barley with 
cold water. Boil it five minutes in fresh water; throw 
both waters away; pour on 2 quarts boiling water; boil 
down to 1 quart. Flavor with thinly cut lemon-rind ; add 
sugar to taste. Do not strain unless at patient's request. 

How to Prepare Cocoa and Chocolate, 
cocoa. 

For each large cup take a teaspoonful of cocoa and 
a teaspoonful of sugar; mix to a paste with a little boil- 
ing water or milk; add balance of milk or milk and 
water, as richness is desired. Let it boil a minute, as 
boiling improves it. 

CHOCOLATE (UNSWEETENED). 

For each breakfastcup take 1 division, break in small 
pieces, and allow to melt; add milk or milk and water, 
as richness is desired. Stir constantly. Bring to a boiling- 
point and set aside to simmer. Sugar to taste. 

CHOCOLATE (SWEETENED). 

Take 1 section of a half-pound cake for each cup. 
Break in pieces in dish and allow to melt without burn- 
ing. Place the dish over a slow fire; add the necessary 
quantity of water and milk. A few minutes' boiling will 
suffice. Stir frequently. Allow to simmer a few minutes. 

When milk is contra-indicated, boil the cocoa or choco- 
late with water only. 

Coffee (French). 

Some persons prefer filtered to boiled coffee. Filtered 
coffee is best made in a French biggin, consisting of two 
tin vessels, one fitting into the other, the upper one being 
supplied with strainers. The coffee, being very finely 



DIETARY. 331 

ground, is placed in this utensil, and the boiling water 
allowed to slowly percolate through it. The pot should 
be set where it will keep hot, but not boil, until the water 
has gone through. Pouring it through the cofTee a second 
time will make it stronger, but it loses in flavor. Cafe 
noir is always made in this way. 

Nutritious Coffee. 

Dissolve a little isinglass or gelatin (Knox) in water; 
put 1 / 2 ounce of freshly ground cofTee into a saucepan 
with 1 pint of new milk, which should be nearly boiling 
before the coffee is added; boil both together for three 
minutes; clear it by pouring some of it into a cup and 
dashing it back again; add the isinglass, and leave the 
coffee on the back part of the range for a few minutes 
to settle. Beat up 1 egg in a breakfastcup, and upon it 
pour the coffee; if preferred, drink without the egg. 

Eggnog. 

Scald some milk by putting it, contained in a jug, 
into a saucepan of boiling water, but do not allow the 
milk to boil. When cold, beat up a fresh egg with a 
fork in a tumbler with some sugar; beat to a froth, add 
a dessertspoonful of brandy, and fill up tumbler with 
the scalded milk. 

Soft Custard. 

Take of cornstarch 2 tablespoonfuls to 1 quart of 
milk; mix the cornstarch with a small quantity of the 
milk, and flavor; beat up 2 eggs. Heat the remainder of 
the milk to near boiling; then add the mixed corn, the 
eggs, 4 tablespoonfuls of sugar, a little butter, and salt. 
Boil the custard two minutes, stirring briskly. 

Calf's-Foot Jelly. 

Thoroughly clean 2 feet of a calf, cut into pieces, and 
stew in 2 quarts of water until reduced to 1 quart ; when 



332 INFANT-FEEDING. 

cold, take off the fat and separate the jelly from the sedi- 
ment. Then put the jelly into a saucepan, with white 
wine and brandy and flavoring to taste, with the shells 
and whites of 4 eggs well mixed together; boil for a 
quarter of an hour, cover it, and let it stand for a short 
time, and strain while hot through a flannel bag into a 
mold. 

Tapioca-cream. 

Take 1 pint of milk, 2 tablespoonfuls of tapioca, 2 
tablespoonfuls of sugar, 1 saltspoonful of salt, and 2 eggs. 
Wash the tapioca. Add enough water to cover it, and let 
it stand in a warm place until the tapioca has absorbed 
the water. Then add the milk and cook in a double boiler, 
stirring often until the tapioca is clear and transparent. 
Beat the yolks of the eggs. Add the sugar and salt and 
the hot milk. Cook until it thickens. Remove from the 
fire. Add the whites of the eggs, beaten stiff. When 
cold, add 1 teaspoonful of vanilla. 

Toasted Bread (Toast, Dry). 

Cut thin slices of bread into strips, toast carefully 
and evenly without breaking, slightly butter, and serve 
immediately on a hot plate. 

Cream-toast. 

Take 1 cupful of cream, 1 saltspoonful of salt, 2 slices 
of dry toast; or make the same as milk-toast, using cream 
in place of the milk. If preferred, the slices of toast may 
be first dipped in hot, salted water. 

Egg-toast. 

Take 1 egg, 1 saltspoonful of salt, 1 cupful of milk, 
6 slices of bread. Beat the egg lightly; add the salt and 
milk. Soak slices of bread in this until soft. Butter a 
hot griddle; put on the bread; when one side is brown, 



DIETARY. 333 

put a bit of butter on each slice, then turn and brown the 
other side. Serve with sugar and cinnamon. 

Milk-toast. 

Take 1 cupful of milk, 1 / 2 tablespoonful of corn- 
starch, 1 / 2 tablespoonful of butter, 2 slices of dry toast, 1 
saltspoonful of salt. Scald the milk. Melt the butter in 
a saucepan; when hot and bubbling, add the cornstarch. 
Pour in the hot milk slowly, beating all the time until 
smooth. Let it boil up once. Then add the salt. Toast 
2 slices of bread. Pour the thickened milk over the slices. 
Let it stand five minutes. Serve. 

Baked Apples. 

Core and pare 2 tart apples; fill the core-holes with 
sugar; grate over the apples a little nutmeg; add a little 
water to baking-pan and put in oven and bake until the 
apples are soft. Serve with rich milk or cream. Sprinkle 
with icing sugar, if not sweet enough. 

MUTTON-SOUP. 

Cut up fine 2 pounds of lean mutton, without fat or 
skin. Add 1 tablespoonful of barley, 1 quart of cold 
water, and a teaspoonful of salt. Let it boil slowly for 
two hours. If rice is used in place of barley, soak the rice 
in water over night, if it is to be boiled in the morning. 

White Celery Soup. 

Take 1 / 2 pint of strong beef -tea; add an equal quan- 
tity of boiled milk, slightly and evenly thickened with 
flour. Flavor with celery-seeds or pieces of celery, which 
are to be strained out before serving. Salt to taste. 

Scrambled Eggs. 

Take 4 eggs, 1 / 2 teaspoonful of salt, 1 saltspoonful of 
pepper, 1 / i cup of milk, and 1 tablespoonful of butter. 



334 INFANT-FEEDING. 

Beat the eggs lightly; add the salt, pepper, and milk. 
Put the butter into a saucepan; when melted and hot, 
add the eggs. Stir over hot water until of a soft, creamy 
consistency. Serve on buttered toast. 

Soft-Boiled Eggs. 

Drop 2 eggs into enough boiling water to cover them. 
Let them stand on the back of stove, where the water will 
keep hot, but not boil, for eight minutes. An egg to be 
properly cooked should never be boiled in boiling water, 
as the white hardens unevenly before the yolk is cooked. 
The yolk and white should be of a jelly-like consistency. 

To Peedigest Eggs. 

Break a fresh egg; after thoroughly stirring add to 
it 2 grains of caroid powder and stir thoroughly. The 
yolk is at once changed into a limpid liquid and soon, 
though not so quickly, the albumin is completely dis- 
solved. This is done at a temperature of from 70° to 
80° F. 

Raw eggs so treated and slightly salted are not un- 
pleasant to the taste. They may be added to a soup, 
poured upon dry toast, or mixed with prepared rice. 

Peedigested Egg-toast. 

Upon 2 pieces of toast pour 2 eggs previously digested 
with caroid as above directed. Now place in oven and 
allow to remain about three minutes. When ready to be 
eaten, hot milk may be poured on the toast. The milk 
cannot be mixed with the egg, or allowed to stand upon 
the toast for any length of time, because the unspent 
strength of the caroid present acting upon the casein of 
the milk will make the entire dish bitter. If eaten imme- 
diately, the milk will be partially peptonized, but it will 
not be bitter. 



DIETARY. 335 

Infant's Food. 

About 1 teaspoonful of gelatin should be dissolved 
by boiling in 1 / 2 pint of water. Toward the end of the 
boiling 1 gill of cows' milk and 1 teaspoonful of arrow- 
root (made into a paste with cold water) are to be stirred 
into the solution, and 1 to 2 tablespoonfuls of cream 
added just at the termination of the cooking. It is then 
to be moderately sweetened with white sugar, when it is 
ready for use. The whole preparation should occupy 
about fifteen minutes. 

Custard Pudding. 

Break 1 egg into a teacup, and mix thoroughly with 
sugar to taste; then add milk to nearly fill the cup, mix 
again, and tie over the cup a small piece of linen; place 
the cup in a shallow saucepan half-full of water and boil 
for ten minutes. 

If it is desired to make a light batter pudding, a tea- 
spoonful of flour should be mixed in with the milk before 
tying up the cup. 

Corn-flour Pudding. 

Take 1 pint of milk, and mix with it 2 tablespoonfuls 
of flour; flavor to taste; then boil the whole eight min- 
utes; allow it to cool in a mold, and serve up with or 
without jam. 

Pice Pudding. 

Take 1 teacupful of rice; wash, and pour over it boil- 
ing water, and let stand five minutes; then drain off the 
water and add a cupful of sugar to the rice, a little nut- 
meg, 2 quarts of milk, and 1 egg. Bake slowly about two 
hours, stirring occasionally until the last half-hour, then 
brown. 

Sago Pudding. 

Same as above recipe, sago being substituted for rice. 



336 infant-feeding. 

Snow Pudding. 

Dissolve V 2 box of gelatin in 1 pint of cold water; 
when soft, add 1 pint of boiling water, the grated rind 
and juice of 2 lemons, and 2 1 / 2 cupfuls of sugar. Let 
the gelatinized water stand until cold and beginning to 
stiffen. Then beat in the well-beaten whites of 5 eggs. 
Pour into a mold and set on ice. Serve with custard 
sauce: 1 quart of rich milk, the yolks of 5 eggs, and 2 
extra eggs added, and 1 / 2 cupful of sugar. Flavor with 
vanilla. 

Peptonized Oysters. 

Mince 6 large or 12 small oysters; add to them, in 
their own liquor, 5 grains of extract of pancreas with 15 
grains of sodium bicarbonate (or 1 Fairchild peptonizing 
tube). This mixture is then brought to blood-heat (98° 
P.), and maintained, with occasional stirring, at that 
temperature thirty minutes, when 1 pint of milk is added 
and the temperature kept up from ten to twenty minutes. 
Finally, the mass is brought to the boiling-point, strained, 
and served. Gelatin may be added, and the mixture 
served cold as a jelly. Cooked tomato, onion, celery, or 
other flavoring suited to individual taste may be added at 
beginning of the artificial digestion. 

Oyster-stew. 

Take 1 pint of oysters, 1 pint of milk, 1 teaspoonful 
of salt, 1 / 4 cupful of water, 1 tablespoonful of butter, and 
1 saltspoonful of pepper. Scald the milk. Wash the 
oysters by adding the water, and remove all shells. Drain, 
saving the liquor. Put the liquor into a stewpan and heat 
slowly. Skim carefully. When clear, add the oysters and 
cook slowly until the edges curl and they are plump. Add 
the hot milk, butter, salt, and pepper, and serve. Do not 
let the oysters boil, as that toughens them and renders 
them indigestible. 



DIETARY. 337 

Oyster-broth. 

Cut into small pieces 1 pint of small oysters; put 
them into 1 / 2 pint of cold water, and let them simmer 
gently for ten minutes over a slow fire. Skim, strain, and 
add salt and pepper. 

Arrowroot Pudding. 

Add the yolks of 2 eggs to the plain arrowroot recipe 
(following), with 1 teaspoonful of powdered white sugar; 
mix well and bake in a lightly buttered dish for ten or 
fifteen minutes. 

Arrowroot. 

Mix 1 teaspoonful of Bermuda arrowroot with 4 
teaspoonfuls of cold milk. Stir it slowly into 1 / 2 pint of 
boiling milk, and let it simmer for five minutes. It must 
be stirred all the time, to prevent lumps and to keep it 
from burning. Add 1 / 2 teaspoonful of sugar and a pinch 
of salt, and, if desired, 1 of cinnamon. In place of the 
cinnamon 1 / 2 teaspoonful of brandy may be used or a 
dozen large raisins may be boiled in the milk. If the 
raisins are preferred, they should be stoned and the sugar 
may be omitted. 

Oatmeal-gruel. 

Pound 1 / 2 cup of coarse oatmeal until it is mealy. 
Put it in a tumbler, and fill the tumbler with cold water. 
Stir well; let it settle; then pour off the mealy water 
into a saucepan. Fill again and pour off the water, and 
again repeat this, being careful each time not to disturb 
the sediment in the bottom of the tumbler. Boil the 
water twenty minutes. Season with salt. Thin with a 
little cream or milk. Strain and serve hot. 

Chicken-broth. 

Skin and chop up a small chicken or half a large fowl ; 
put, bones and all, — with a blade of mace, a sprig of 



22 



338 INFANT-FEEDING. 

parsley, 1 tablespoonful of rice, and a crust of bread, — in 
a quart of water and boil for an hour, skimming it from 
time to time. Strain tbrougb a coarse colander. 



Clam-broth. 

"Wasb thoroughly 6 large clams in the shell ; put them 
into a kettle with 1 cupful of water; bring to boil, and 
keep it boiling one minute; the shells open, the water 
takes up the proper quantity of juice, and the broth is 
ready to pour off and serve hot. Add a teaspoonful of 
finely-pulverized cracker-crumbs, a little butter, and salt 
to taste. 

RlCE-WATER. 

One ounce of well-washed Carolina rice. Macerate 
for three hours at a gentle heat in a quart of water, and 
then boil slowly for an hour and strain. It may be sweet- 
ened and flavored with a little lemon-peel. Useful in 
diarrhoea, etc., when the flavoring is best dispensed with, 
and a little old. cognac added. 

Barley-water. 

Take a tablespoonful of pearl barley, grind it in a 
coffee-grinder, or pound it in an ordinary mortar; add 
1 pint of cold water, and allow it to simmer slowly for 
about an hour. Strain and add enough water to make 
1 pint. 

Oatmeal- water. 

Take a tablespoonful of ordinary oatmeal, and add 1 
pint of water. Allow it to simmer slowly for one hour 
and strain. Add enough water to make 1 pint. The same 
directions apply to making a household mixture of farina- 
water, rice-water, and sago-water, using the same propor- 
tions as above. 



DIETAEY. 339 

Aeeoweoot-watee. 

Add 2 tablespoonfuls of arrowroot to 1 pint of water; 
allow it to simmer for half an hour, stirring it constantly. 

Egg-watee. 

This is made by mixing thoroughly the white of 1 
egg with 6 ounces of water and adding a little salt. The 
addition of a few grains of sugar will make the child take 
it better, and adds also a food-element. 

Such a mixture is one of the best foods we have for 
temporarily feeding an infant with digestive disturbances 
when we wish to stop temporarily all milk-food. 

Aetificial Milk. 

One ounce of suet cut up very finely, and tied loosely 
in a muslin bag. Boil slowly for an hour in thin barley- 
water, with 1 / 4 ounce of isinglass and a little sugar of 
milk, adding a little water occasionally as it boils away. 
Pound up 12 sweet almonds, pour the fluid slowly on 
them, and incorporate well. Strain before using. 

Milk Thickened. 

A great deal of nourishment can be given in milk 
by thickening it with either wheat-flour, rice-flour, isin- 
glass, or gum arabic. The method of doing so is this: 
with 

Whmt-floiir. — Rub a large spoonful of flour quite 
smooth, in a few spoonfuls of cold milk. Then add more 
milk by degrees till you have 1 / 2 pint. Sweeten and 
flavor with a little cinnamon, and then boil up the milk, 
stirring it all the time to prevent its getting lumpy. 

Rice- flour is done in exactly the same way. 

To thicken milk with isinglass, boil 1 / 2 ounce of it 
in a pint of new milk, sweetened and flavored. When boil- 
ing, strain it off. A little less isinglass will do, unless the 
milk is desired very thick. 



340 INFANT-FEEDING. 

For thickening with gum arabic the proportions will 
vary according as the milk is wanted more or less thick. 
If powdered gum arabic is used, it is done in the same 
way as flour; but if lumps, drop them into hot milk, until 
it is of the desired thickness, and then boil. There is 
much nourishment in this hot, and it is very soothing 
where either chest or stomach are in an irritable state. 



Rice-milk. 

Three tablespoonfuls of rice, 1 quart of milk; wash 
the rice and put into a saucepan with the milk; simmer 
until the rice is tender, stirring now and then, and 
sweeten. Tapioca, semolina, vermicelli, and macaroni 
may be similarly treated. 

Humanized Milk. 

A pint of milk is set aside until the cream rises, and 
this cream is skimmed off and kept. To the milk remain- 
ing is added enough rennet to curdle it. The whey is 
strained off the curd and added, with the previously 
separated cream, to a pint of fresh cows' milk. This is 
known as humanized milk. In some infants it will be 
well borne during the first three months, and to this can 
be added farinaceous liquid for dilution if required. 

Pasteurized Milk. 

This is really partially sterilized milk, and consists 
of sterilization at a temperature of 140° F. instead of 
212° F., this sterilization to be continued for from 
twenty minutes to half an hour. Pasteurized milk should 
only be used during the twenty-four hours following this 
process. A good apparatus for this purpose is the one 
known commercially and to physicians as Freeman's pas- 
teurizing apparatus. 



DIETARY. 341 



Peptonized Milk. 



This is milk in which the proteids are changed to 
peptones, or, in other words, digested, by the addition 
and action of pancreatic ferment. This process may be 
stopped when partially performed, giving a product of 
which the taste is not objectionable; or it may be carried 
on to complete peptonization, when the product has a very 
bitter, disagreeable taste. 

Method. — To peptonize milk partially, add to 1 pint 
of fresh cows' milk and 4 ounces of water 5 grains of 
pancreatic extract and 15 grains of bicarbonate of soda. 
Allow this to stand at a temperature of 105° to 115° F. 
for five to twenty minutes, then bring to a boil to kill 
the ferment, or stand on ice to prevent its further action. 
If the milk is to be used at once, neither of these latter 
is necessary. 

To peptonize the milk completely, allow the process 
to continue for one to two hours. After this time the 
addition of acid produces no coagulation. 

In infant-feeding it is better to peptonize a modified 
than a whole milk. Peptonized milk is frequently very 
useful in feeding an infant with feeble digestive powers; 
but it is unwise to continue its use over too long a period, 
as then the infant's stomach, being called on to do no 
work, becomes enfeebled from disuse, and gradually un- 
able to perform its proper function. 

Whey. — By coagulating 1 pint of fresh milk by add- 
ing a teaspoonful of essence of pepsin, and allowing this 
to stand, a solid curd is formed swimming in a liquid 
(whey). This has the following composition: Proteids, 
0.86 per cent.; fat, 0.32 per cent.; sugar, 4.79 per cent.; 
salts, 0.65 per cent.; water, 93.38 per cent. 

This at times makes a very valuable food for infants 
in cases of gastric or intestinal disorder, where the use of 
milk must for a time be interdicted. Babies like it, it is 
very easy of digestion, and does not irritate the stomach. 
A little wine may be added if desired. 



342 infant-feeding. 

Scraped Beef. 

This is another valuable and easily digested food. It 
is prepared by scraping with a dull knife some raw or 
underdone lean beef. A tablespoonful of this salted is 
the amount usually given at a feeding. 

Beef-tea in Haste. 

Scrape 1 pound of lean beef into fibres on a board. 
Place the scraped meat in a delicately clean white-lined 
saucepan and pour 1 / 2 pint of boiling water upon it. 
Cover closely and set by the side of the fire for ten min- 
utes; strain into a teacup, place the teacup in a basin of 
ice-cold water; then remove all fat from the surface, pour 
into a warm cup, warm this gently with hot water or 
otherwise, and serve. This can be ready in fifteen min- 
utes, and double the quantity of meat can be used if 
necessary. Bread and blotting-paper are ineffectual to 
remove all the fat. A tomato makes excellent flavoring, 
and other flavors can be added if desired. For children, 
however, the simpler aliments are the better. 

Beef-and-Chicken Broth. 

One pound of good lean beef and a chicken boned 
should be pounded together in a mortar, and a little salt 
added, and the whole placed in a saucepan with nearly 3 
pints of cold water. Stir over the fire until it boils, then 
boil half an hour, strain through a coarse sieve, and serve. 

Liebig's Extract of Beef Thickened. 

A teaspoonful of Liebig's extract may be added to a 
pint of boiling barley-water, with a little salt, or to this 
may be again added a teacupful of milk, or, instead of 
the milk, the whites of 2 eggs beaten up with 2 tablespoon- 
fuls of milk may be stirred into the Liebig beef-tea and 
barley-water when cool enough to be taken. Too great 
heat will coagulate the albumin. 



DIETARY. 343 

Chicken-, Veal-, and Mutton- broths. 

The fleshy part of the knuckle of veal; a chicken, 
bones and all chopped up; or 2 pounds of the scrag end 
of neck of mutton, added to 2 pints of water, with a little 
pepper and salt, and boiled two hours and strained, all 
make excellent broths. Pearl barley, rice, or vermicelli, 
boiled separately till quite soft, may be added when either 
of the broths is heated for use. All fat must always be 
carefully removed by skimming when cold. 

Beef-juice. 

Expressed beef-juice is obtained by slightly broiling 
a piece of lean beef, and then squeezing the juice from it 
by a lemon-squeezer. One pound of steak yields 2 or 3 
ounces of juice. This is flavored with salt and given cold 
or warm. Do not heat enough to coagulate the albumin. 
This is very nutritious and usually well taken. It may 
be given at the rate of a tablespoonful three times a day. 

Good, Nutritious Beef-tea. 

Mince 1 pound of good beef (from which all skin, fat, 
etc., has been carefully removed) and pour upon it in an 
earthen jar 1 pint of cold water. Stir, and let it stand for 
one hour. Then place the jar in a moderate oven for one 
hour, or stand the jar in a saucepan of water and allow 
the water to boil gently for an hour. To be exact, the 
heat to which the beef-tea is raised should not exceed 
180° F. Strain through a coarse sieve and allow it to 
grow cold. When wanted, remove every particle of fat 
. from the top ; warm up as much as may be required, add- 
ing a little salt. Beef-tea should, except in the hottest 
weather, be made a day before it is wanted. 

Essence of Beef (with Heat). 

One pound of gravy-beef free from skin and fat, chop 
as fine as mincemeat, pound in a mortar with 3 table- 



344 INFANT-FEEDING. 

i 

spoonfuls of soft water, and soak for two hours. Then 
put in a covered earthen jar with a little salt, cement the 
edges of the cover with pudding paste, and tie a piece of 
cloth over the top. Place the jar in a pot half-full of 
boiling water, and keep the pot on the fire for four hours, 
simmering. Strain off the liquid essence through a coarse 
sieve; it will be about 5 or 6 ounces in quantity. One 
teaspoonful frequently, with or without wine or brandy, 
as may be ordered. A teaspoonful of cream may occa- 
sionally be added with advantage to 4 ounces of the 
essence, or it may be thickened with flour, arrowroot, or 
sago. 

Essence of Beef (Another Way, Without Heat). 

Half a pound of fresh beef cut up as finely as pos- 
sible; to this add 1 / 2 pint of pure, soft, cold water (rain- 
water is excellent, filtered, if necessary, from the nature 
of the vessels in which collected, as iron tanks, etc.); an 
eggspoonful of salt, and 5 drops of pure hydrochloric acid 
(spirit of salt). Mix and stir well, and after an hour filter 
through a conical sieve without pressure. The fluid must 
be returned into the sieve until it runs through clear. 
Next, another 1 / 2 pint of cold, pure, soft water is to be 
poured on the meat in the sieve, and this is also to run 
through without pressure. The result will be about 3 / 4 
pint of a red solution of meat containing most of the 
albumin, coloring and flavoring matters, salts, and other 
soluble materials. Half a wineglassful of this may be 
taken cold for a child twelve years old; a teaspoonful to 
a dessert or tablespoonful for younger children. Or it 
may be slightly warmed by standing in a jar immersed in 
hot — not boiling — water. It may be colored with burnt 
sugar, if desirable. This is a veritable meat-essence, and 
is of use in extreme prostration, notably after burns, in 
continued fever, in some cases of dyspepsia, and in the 
diarrhoea of infants, as alluded to elsewhere. 



DIETARY. 3-15 



Fresh Pabttla. 



These contain essentially the so-called antiscorbutic 
element, and may be given, not only to provide this un- 
known but necessary constituent of food, but also as 
additional nutrient agents. The chief articles are: — 

Raw Meat- juice. — To prepare this take 2 ounces of 
gravy-beef, free from fat, and chop into small pieces ; add 
to 2 ounces (4 tablespoonfuls) of water in a cup, and stand 
in a warm place for half an hour; then squeeze through 
muslin to express the juice. The temperature of the 
meat-juice must never be above lukewarm, or the soluble 
albuminoids will be coagulated and its value destroyed. 
Raw meat-juice will not keep for more than 10 or 12 
hours, and should be made fresh whenever wanted. 

Bananas. — Fresh ripe bananas, either grated or 
sieved, afford a valuable fruit food. It has been found 
that bananas with milk will constitute a useful nourishing 
food for infants. 

Egg-albumin. — Egg-albumin is prepared for use by 
stirring up the white of 1 new-laid egg with 4 ounces of 
water. Prepared thus and sweetened, it may take the 
place, for a time, of the ordinary milk diet in infantile 
diarrhoea, after appropriate treatment with repeated small 
doses of calomel. Egg-albumin can hardly be considered 
as a substitute for raw meat-juice, which contains only 
about 3 per cent, of albumin (myosin), but which is a 
powerful digestive stimulant, owing to the presence of 
extractives (creatin, etc.). 



LIST OF BOOKS CONSULTED. 



Baginsky: "Diseases of Children," 1902. 

Henoch: "Diseases of Children." 

Biedert : "Infant-feeding." 

Monti: "Infant-feeding and Dietetics." 

Jacobi: "Intestinal Diseases of Infancy and Childhood." 

Jacobi: "Therapeutics of Infancy and Childhood." 

Article by T. M. Botch, in Jacobi "Festschrift." 

Hammersten : "Text-book of Physiological Chemistry." 

Hammersten: Eichhorst, "Clinical Pathology." 

Archiv fur Kinderheilkunde (editor, Professor Baginsky). 

Wing: "Milk and its Products." 

Ellis: "Diseases of Children." 

Tuttle Gallaudet: "Diseases of Children." 

Keating : "Encyclopaedia." 

H. Neumann, Berlin: "Ernahrungsweise und Infectionskrankheiten 

im Sauglingsalter." 
W. Knoepfelmacher, Vienna: "Verdauungsruckstande bei der 

Ernahrung Mit Kuhmilch." 
Sternberg: "Manual of Bacteriology." 
Hueppe: "Principles of Bacteriology." 
Pfeiffer: "Analysis of Milk," Wiesbaden, 1887. 
Heubner: "Sauglingsernaehrung und Saeuglings-spitaeler," Berlin, 

1897. 
Holt: "Diseases of Children." 

R. Schroter: "Jahrbuch fur Kinderheilkunde," 1887. 
A. Wroblewski: "Beitrage zur Kenntnis des Frauencaseins, etc. 

Mittheilungen aus den Kliniken und medicinischen Instituten 

der Schweiz," 1894. 
J. Lehmann: "Milchuntersuchungen," Pfluger's Archiv, 1894. 
Fr. Soldner: "Die Salze der Milch," etc. Inauguration dissertation, 

Langensalza, 1888. 
Th. Escherich: "Jahrbuch fur Kinderheilkunde," 1891. 
E. Salkowski and M. Hahn: Pfluger's Archiv, 1895. 
H. Wegscheider: "Ueber die normale Verdauung bei Sauglingen," 

Berlin, 1875. 
0. Heubner: "Berliner klinische Wochenschrift, 1894. 
J. Uffelmann: Pfliiger's Archiv, 1882. 

(346) 



LIST OF BOOKS CONSULTED. 347 

Biedert: "Jahrbuch fiir Kinderheilkunde," 1881. 

Th. Escherich: Miinchener medicinische Wochenschrift, 1889. 

F. Soxhlet: Mtinchener medicinisclie Wochenschrift, 1893. 

Th. Escherich: "Verhandhingen der XI Versammlung der Gesell- 

schaft fiir Kinderheilkunde," 1894. 
Gartner: IMdem, 1894. 
A. Jacobi: in Gerhardt's "Handbuch der Kinderheilkunde." 



INDEX. 



PAGE 

Absorption 21 

of carbohydrates 14 

of fat 10 

Achroodextrin 11 

Acid, hydrochloric, the addition of, to food 72 

lactic, quantity of, in infant's stomach 3 

Acidity, relative, of an infant's stomach 2 

Acids in the infant's stomach . 2 

After weaning, time of feeding 84 

Albumin and the gastric juice 15 

-water 329 

Albuminose 29 

Albuminous, or proteid, substances 29 

Almond-milk 321 

Amylopsin 11 

Apple-water .' 329 

Arrowroot 337 

pudding 337 

-water 339 

Athrepsia infantum 303 

causes of 305 

feeding in 305 

stages of 303 

Bacillus acidi lactici 113 

"b," summary of 53 

"d" of Booker 44 

"e" of Booker 45 

"f" of Booker 46 

"g" of Booker 48 

"h" of Booker 49 

"k" of Booker 49 

"n" of Booker 50 

Backhaus's milk 221 

Bacteria of the intestine 39 

Bacterium coli commune 39 

biological characters of 41 

morphology of 40 

pathogenesis of 43 

varieties of 44 

Bacterium laetis aerogenes 51 

biological characters of 52 

morphology of 51 

pathogenesis of 52 

Baked apples . 333 

Bananas 345 

(348) 



INDEX. 349 

PAGE 

Barley-water 330, 338 

Barlow's disease from improper feeding 183 

Beef-and-chicken broth 342 

essence of 343, 344 

-juice 343 

scraped 342 

-tea 343 

-tea in haste 342 

Biedert's cream,, directions for making 146 

cream-mixtures 146 

Bile, cholesterin in 18 

glycocholic acid in 18 

in nurslings 18 

lecithin in 18 

mucin in 18 

quantity of 18 

unorganized ferments in 18 

Bottle-brush 188 

-feeding 144 

amount of milk to be given in 144 

general rules for 151 

Breast-feeding 67 

rules for 67 

suggestions for 68 

time for 67 

Breast-milk 60 

composition of » 62 

immunity by 56 

proteids, method for estimation of 31 

-pump 90 

specimen of, for chemical examination 64 

Brooder 107 

Buttermilk feeding 115 

how to prepare for infants 115 

quality of 118 

Calf s-foot jelly 331 

Cane-sugar 130 

Carbohydrates 26 

and their formulae 21 

Cellulose 22 

Cereal milk 211 

composition of, when prepared 211 

Chicken-broth 337 

veal-, and mutton- broths 343 

Chloride of sodium 28 

Chocolate 227 

sweetened 330 

unsweetened 330 

Clam-broth 38 

Clinical illustrations of how to feed 154 

Cocoa 226 

and chocolate cocoa, how to prepare 330 

Coffee, French 330 



350 INDEX. 



PAGE 

Coffee, nutrition 331 

Coit's decimal method for home-modification of milk 148 

Colic 271 

causes of 27 1 

drug treatment of 273 

massage in 272 

sugar as a cause of 274 

Colostrum 30, 55 

Condensed milk or cream 224 

quantity of sugar in 224 

Constipation 275 

causes of 276 

dietetic treatment of 284 

drug treatment of 280 

electricity in 283 

exercise for 284 

hygienic treatment of 285 

immediate relief of 279 

massage in 283 

water for 279 

Corn-flour pudding 335 

Cow, the breed of a 127 

Cows, age of 128 

tuberculin reaction in Ill 

Cows' food 110 

Cows' milk 107 

albuminoids in 129 

analysis of 107 

average percentage of fat in 110 

composition, variation, and production of 107 

lime-salts in 33 

properties of 97 

raw 98 

solutions for rendering alkaline 140 

yellowish 112 

Cream 134 

decimal . . 148 

eight-per-cent 135 

for home-modification 134 

how to procure 135 

-mixture, Biedert's 145 

ordinary 134 

to pasteurize the 136 

-toast 332 

twelve-per-cent 135 

uses of 134 

Curds and whey 327 

Custard pudding 335 

Cyanosis in premature infants 198 

Dairy, the ideal 133 

Dentition 299 

Dextrose 11 

alcoholic fermentation of 12 



INDEX. 351 

PAGE 

Diastasic action of succus entericus 12 

Diastasis 22 

Diet after the period of weaning 87 

Dietary 321 

Dietetic management of a bottle-fed baby 318 

Dried-milk foods 206 

Drags taken by a nursing woman, influence of on baby 69 

Egg-albumin 345 

-toast 332 

-water 339 

Eggnog 331 

Eggs, scrambled 333 

soft-boiled 334 

to predigest 334 

Enzymes 22 

Epithelium and the glands, secretory and absorbing power of.. 16 

Erythrodextrin 11 

Eskay's albumenized food 214 

composition of, when prepared 215 

Fasces, peptonizing ferment in 266 

proteids in 266 

quantity of 265 

saccharin ferment in 266 

Farinaceous dried-milk foods 207 

Fat, absorption of 27 

diarrhoea 265 

-globules in milk 71 

Fats 26 

and carbohydrates, value of 27 

Feeding children afflicted with cleft palate 260 

forced 195, 250 

dangers of 196 

in diphtheria-intubation cases 254 

infants, general rules for 105 

mixed 69 

nasal 252 

in diphtheria 257 

modus operandi of 252 

quantity of food in 252 

of infants in incubators 194 

method of 194 

results of 199 

of sick children 72 

rectal, general rules for 258 

in diphtheria 254 

rules for 152 

-table and cream-mixtures 145 

-bottles 189 

Fermentation 12, 13 

lactic 12 

of sugar 13 

Ferments and their actions 11 



352 INDEX. 



PAGE 

Ferments, organized 20 

unorganized, table of 19 

Flour-ball feeding 71 

Food, addition of hydrochloric acid to 72 

Foods, additional, during the nursing period 71 

Freeman's pasteurizer 180 

Gas in the intestine, function of 15 

Gastric juice, influence of, on pathogenic germs 4 

of infantile stomach 2 

power of transforming albumin 15 

Gavage 250 

Giaourdi 114 

Glandular system of infants, development of 16 

Glucose 12 

Grape-sugar 11 

Gruels, dextrinized 191 

method of dextrinizing 191 

Gum-arabic water 328 

Hand-feeding 144 

Home modifier, materna 166 

Horlick's malted milk 209 

composition of, when prepared 209 

Humanized milk 217 

composition of, when prepared 217 

directions for 323 

Hydrocarbons 26 

Hydrochloric acid in the infant's stomach 2 

Hydrolysis 22 

Hydrolytic agents 20 

Ice-cream and water-ices 227 

Imperial granum 213 

composition of, when prepared 213 

Incubator treatment of premature infants, results of 199 

-feeding 194 

Incubators, method of feeding in 194 

Infant-feeding 103 

in summer complaint 317 

Infant-foods 206 

as adjuncts to fresh cows' milk 206 

Infant-stools 261 

Infants, general rules for feeding 105 

premature 197 

Infants' food 335 

saliva 2 

weight . . . .' 92 

Intestinal muscles, action of 16 

Intestine, infantile, formation of gas in 15 

Intestine, length of 15 

Junket 327 

of milk and egg 322 



ixdex. 353 



PAGE 

Keller's malt-soup 231, 321 

Koumiss 114 

Laboratory modification of milk 236 

Lactose 13 

Lahmann's vegetable-milk 222 

Lemonade 328 

Levulose - 13 

Liebig's extract of beef, thickened 342 

Lime-salts in cows' milk 33 

-water 328 

and milk 34 

Liver and bile in nurslings 18 

Long rubber tubes 190 

Malassimilation of food 303 

Malt-diastase, action of 23 

-extracts 193 

Malted dried-milk foods 207 

Maltose 11, 12 

Mammary glands, the two 56 

Marasmus 303 

Meat, raw, beneficial effects of 102 

Mellin's food 215 

composition of, when prepared 215 

formulae and analyses for preparing 216 

Men suckling children 5S 

Microbes in the milk of nursing women 70 

Milk, addition of glycerin to 140 

sugar to 139 

aerated 204 

albuminoids of 64 

and albumin 329 

artificial 339 

bacteriology of - 125 

bicarbonate of soda in 34 

burettes 31 

certified 204 

changes in, by boiling 171 

by sterilization 164 

curdling and diluents of 129 

detection and addition of preservatives to 122 

directions for pasteurizing 179 

effect of alkalies on 128 

of heating 164 

fat in 25 

formaldehyde as an addition to 122 

fresh raw 100 

frozen 113 

home-modification of 148 

human, properties of 96 

modification of 136 

of men's breasts 59 

pasteurization of 172 

23 



354 INDEX. 



PAGE 

Milk, pasteurized 177, 340 

peptonized 341 

phosphorus in 64 

proteids in •. 31 

raw, assimilation of 100 

salicylic acid as an addition to 124 

salts contained in 131 

Soxhlet's method of sterilizing 174 

sour 113 

sterilized 173 

substitute for, in diseases of stomach and intestines .... 10G 

sugar in 25 

-teeth 299 

test for salicylic acid in 124 

tests for formaldehyde in 122 

thickened 339 

witch's 57 

woman's, methods of changing the ingredients in 78 

idiosyncrasies in children 228 

-modifying gauge 168 

-punch 329 

salty 126 

-sugar 35 

bacteria in 38 

impurities in 37 

process of making 35 

solutions 138 

-toast 333 

Milkine 210 

Milking, precautions necessary in 127 

Milking time and stage of 128 

Mother-milk, Professor Gaertner 218 

Muscles, intestinal, action of 16 

Mutton-soup 333 

Nathan Straus milk-laboratories and similar charities 268 

Nestle's food 208 

Nipple, ventilated 187 

-shield 89 

-sterilizer 188 

Nipples and bottles 185 

artificial 185 

mode of cleansing 185 

management of woman's 89 

before the baby is born 89 

odor of 188 

recommended 187 

tender 90 

Nursing centre 2 

mother, the diet of a 73 

Oatmeal-gruel 337 

-water 338 

Orangeade 329 



INDEX. 355 

PAGE 

Oyster-broth 337 

-stew 336 

Oysters, peptonized 336 

Partially peptonized milk 325 

Pepsin and hydrochloric acid in infant's stomach 3 

Peptogenic milk-powder 217, 322 

Peptones 20 

Peptonized milk 325 

milk-gruel 326 

Predigested beans 324 

peas 324 

eggs 334 

egg-toast 334 

food 324 

how to prepare 324 

rice 324 

Ptyalin 11 

Putrefaction 20 

Racahout powder 318 

Rachitis 288 

causes of 2S0 

diet required in 201 

external treatment of 201 

internal treatment of 202 

prevention of 288 

prognosis of 201 

Raw meat-juice 345 

Rectal alimentation in summer complaint 318 

Rice-milk 340 

-pudding 335 

-water 338 

Saccharated skim-milk 140 

Sago-pudding 335 

Saliva, action of, on various bacteria 4 

secretion of 2 

Salts 28 

and water 20 

Schedule for feeding and formulae 153 

Schizomycetes, intestinal, diastasic action of 12 

Scorbutus 204 

Scurvy 101, 204 

avoidance of 105 

value of milk in 105 

Scybala, removal of 280 

Secretory and absorbent power of the epithelium and glands . . 16 

Self-weaning 84 

Sick children, the feeding of 72 

Siphon, to clean the glass 137 

Snow-pudding 336 

Soft custard 331 

Starch, saccharification of 22 



356 INDEX. 



PAGE 

Starch, soluble 22 

Statistics of births and deaths 286 

Sterility of human milk 70 

Stomach, acids in the 2 

amount of secretion in 2 

capacity 6 

infantile 1 

mucous membrane of the 1 

muscular fibres of 1 

ptyalin in 11 

quantity of lactic acid in 3 

relative acidity of 2 

Stool, dyspeptic 265 

of a nursling 261 

Stools 263 

blood in 263 

brown 263, 264 

casein in 265 

jelly-like masses in 264 

long shreds of mucus in 265 

mucus in 264 

muddy 264 

reaction of 262 

typical green 263 

white or light gray 264 

Succus entericus, diastasic action of 12 

Sucrose 13 

Sucking act 2 

centre 2 

Sugar, contra-indications to the use of 139 

in milk 25 

solution, standard 149 

Summer complaint in a nursing infant 320 

Tamarind-water : 328 

Tapioca-cream 332 

Tea 329 

Teething 299 

Toast, dry 332 

-water 329 

Toasted bread 332 

Top-milk 135 

Tuberculous diseases in children, causes of 112 

Tyndallization 183 

Walker-Gordon laboratory milk 236 

Wampole's milk-food 212 

composition of when prepared 212 

Wasting disease 303 

Water in the feeding of infants 142 

quantity of, to be given to infants 142 

Weaning 76 

and feeding from one year to fifteen months 82 



index. 357 



PAGE 

Weighing to determine the quantity of milk an infant has 

taken 93 

Weight-chart for an infant 95 

Wet-nurse 76 

diet of a 77 

manner of living 77 

Wet-nursing 79 

Whey 326, 328 

White celery soup 333 

Zomotherapy 102 



OCT 23 1903 



